Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 531: An ultrasound finding in a pregnant female shows a 'snowstorm' appearance, which is characteristic of hydatidiform mole. What is the most common gestational trophoblastic disease that follows a hydatidiform mole?

A. Invasive mole (Correct Answer)
B. Choriocarcinoma
C. Placental site trophoblastic tumor
D. Placental nodule

Explanation: **Explanation:** The correct answer is **Invasive mole**. **1. Why Invasive Mole is Correct:** Gestational Trophoblastic Disease (GTD) represents a spectrum of tumors arising from the placenta. Following a hydatidiform mole (especially a complete mole), approximately 15–20% of patients develop Gestational Trophoblastic Neoplasia (GTN). Among these cases, **Invasive mole** is the most common histological type, accounting for nearly **70–80%** of post-molar GTN. It is characterized by the presence of hydropic villi that invade the myometrium or its blood vessels. **2. Why Incorrect Options are Wrong:** * **Choriocarcinoma:** While it is the most aggressive form of GTN and can follow a mole, it is less common than an invasive mole (occurring in about 2–3% of molar pregnancies). It is characterized by the absence of chorionic villi. * **Placental Site Trophoblastic Tumor (PSTT):** This is a very rare form of GTN arising from intermediate trophoblasts. It more commonly follows a full-term pregnancy or abortion rather than a hydatidiform mole. * **Placental Nodule:** This is generally a benign, incidental finding representing a remnant of a previous pregnancy and is not considered a malignant gestational trophoblastic disease. **Clinical Pearls for NEET-PG:** * **Snowstorm appearance:** The classic ultrasound finding for a complete hydatidiform mole (due to multiple hydropic villi). * **Risk of Malignancy:** Complete moles have a higher risk (15–20%) of progressing to GTN compared to partial moles (<5%). * **Diagnosis of GTN:** Usually made by the **FIGO criteria** based on plateauing or rising serum β-hCG levels post-evacuation, rather than histology. * **Treatment:** Invasive moles are highly sensitive to chemotherapy (Methotrexate is the first-line drug for low-risk cases).

Question 532: A female with a history of trophoblastic disease has what percentage of chances of developing trophoblastic disease in the next pregnancy?

A. 2% (Correct Answer)
B. 5%
C. 8-12%
D. 15-20%

Explanation: **Explanation:** The risk of recurrence for Gestational Trophoblastic Disease (GTD) is a high-yield statistical fact in NEET-PG. After one molar pregnancy, the risk of recurrence in a subsequent pregnancy is approximately **1–2%**. This is significantly higher than the baseline population risk (approx. 0.1%), but the majority of women will still have a normal subsequent pregnancy. * **Why 2% is correct:** Large epidemiological studies indicate that the risk of a repeat hydatidiform mole is roughly 1 in 50 to 1 in 100 pregnancies. If a woman has **two** prior molar pregnancies, the risk increases drastically to about **15–20%**. * **Why 5% is incorrect:** This overestimates the risk after a single molar pregnancy. * **Why 8–12% is incorrect:** This range does not correlate with standard clinical data for first or second recurrences. * **Why 15–20% is incorrect:** This is the specific recurrence risk for a woman who has already had **two** previous molar pregnancies. **Clinical Pearls for NEET-PG:** 1. **Follow-up:** After a molar pregnancy, patients must be monitored with weekly serum β-hCG levels until three consecutive normal results are obtained. 2. **Contraception:** Combined Oral Contraceptive Pills (COCPs) are the preferred method during follow-up once hCG levels begin to fall; they do not increase the risk of post-molar GTN. 3. **Future Pregnancies:** In any future pregnancy, an early ultrasound (first trimester) is mandatory to confirm normal development, and the placenta should be sent for histopathology.

Question 533: According to the WHO classification of ovarian tumors, to which category does a Brenner tumor of the ovary belong?

A. Epithelial tumors (Correct Answer)
B. Sex cord-stromal tumors
C. Germ cell tumors
D. Metastatic tumors

Explanation: **Explanation:** The **Brenner tumor** is a unique subtype of **Surface Epithelial-Stromal tumors** of the ovary. It is characterized histologically by nests of transitional epithelium (urothelium) embedded within a dense fibromatous stroma. These epithelial nests often contain "coffee-bean" nuclei (longitudinal nuclear grooves), similar to those seen in Granulosa cell tumors. **Why Option A is correct:** The WHO classifies ovarian tumors based on their tissue of origin. Brenner tumors arise from the surface epithelium or from Walthard cell rests (small clusters of transitional cells). Therefore, they are categorized alongside serous, mucinous, endometrioid, and clear cell tumors as epithelial neoplasms. **Why other options are incorrect:** * **B. Sex cord-stromal tumors:** These arise from the ovarian mesenchyme (e.g., Granulosa cell tumors, Sertoli-Leydig tumors, Fibromas). While Brenner tumors have a prominent fibrous component, the defining neoplastic element is epithelial. * **C. Germ cell tumors:** These arise from primordial germ cells (e.g., Teratoma, Dysgerminoma, Yolk sac tumor). * **D. Metastatic tumors:** These are secondary tumors spreading from other sites (e.g., Krukenberg tumor from the stomach). **High-Yield Clinical Pearls for NEET-PG:** * **Gross Appearance:** Usually solid, unilateral, and yellowish-white (resembling a fibroma). * **Histology:** Look for **"Coffee-bean nuclei"** and **Walthard cell rests**. * **Nature:** Most Brenner tumors are **benign**; however, borderline and malignant variants exist. * **Association:** They are occasionally associated with mucinous cystadenomas in the same ovary.

Question 534: Which of the following is a tumor marker for ovarian cancer?

A. CA125 (Correct Answer)
B. CA19-9
C. AFP
D. hCG

Explanation: **Explanation:** **CA125 (Cancer Antigen 125)** is the most widely used tumor marker for **Epithelial Ovarian Cancer (EOC)**, particularly the serous subtype. It is a glycoprotein produced by derivatives of the coelomic epithelium (pleura, pericardium, and peritoneum). While it lacks specificity for screening (as it can be elevated in endometriosis, PID, or menstruation), it is the gold standard for **monitoring treatment response** and detecting recurrence in post-menopausal women with ovarian masses. **Analysis of Incorrect Options:** * **CA19-9:** Primarily used for **Pancreatic and Cholangiocarcinoma**. In gynecology, it may be elevated in Mucinous Ovarian Tumors, but CA125 remains the primary marker for general ovarian malignancy. * **AFP (Alpha-Fetoprotein):** A specific marker for **Yolk Sac Tumors** (Endodermal Sinus Tumors) and Hepatocellular Carcinoma. * **hCG (human Chorionic Gonadotropin):** The hallmark marker for **Choriocarcinoma** and Hydatidiform moles. It is also elevated in some dysgerminomas (if syncytiotrophoblastic giant cells are present). **High-Yield NEET-PG Pearls:** * **Germ Cell Tumor Markers:** * *Dysgerminoma:* LDH (Most specific), hCG. * *Yolk Sac Tumor:* AFP. * *Immature Teratoma:* AFP, LDH, CA125. * **Granulosa Cell Tumor:** Inhibin B (Most sensitive for monitoring). * **Meigs’ Syndrome:** Triad of Benign Ovarian Fibroma, Ascites, and Pleural Effusion (CA125 can be elevated here despite being benign). * **RMI (Risk of Malignancy Index):** Uses CA125 levels, Ultrasound findings, and Menopausal status to assess ovarian masses.

Question 535: A 26-year-old female with three living children presents with cervical erosion that bleeds to touch. How can this be diagnosed?

A. Pap smear, Colposcopy, Diagnostic procedures
B. Excision biopsy, Colposcopy, Diagnostic procedures
C. Pap smear, Excision biopsy, Diagnostic procedures (Correct Answer)
D. Pap smear, Excision biopsy

Explanation: **Explanation:** The clinical presentation of a **cervical erosion that bleeds on touch** (contact bleeding) in a multiparous woman is a classic red flag for cervical malignancy. In any patient with a visible, suspicious lesion, the primary goal is to rule out invasive cervical cancer. **1. Why Option C is Correct:** The diagnostic protocol for a suspicious cervical lesion follows a systematic approach: * **Pap Smear:** Used as the initial screening tool to identify cytological abnormalities. * **Excision Biopsy (Punch/Directed Biopsy):** This is the **gold standard** for diagnosis. When a lesion is visible and bleeds on touch, a biopsy must be performed to obtain a histopathological diagnosis, regardless of the Pap smear result. * **Diagnostic Procedures:** Once malignancy is confirmed, further procedures (such as cystoscopy, proctosigmoidoscopy, or imaging) are required for **clinical staging** according to FIGO guidelines. **2. Why Other Options are Incorrect:** * **Option A & B:** These include **Colposcopy**. While colposcopy is vital for evaluating subclinical lesions (CIN) or abnormal Pap smears with no visible growth, it is generally not the primary diagnostic step for a **frankly suspicious, bleeding lesion**. In such cases, a direct biopsy is prioritized to avoid delay. * **Option D:** This is incomplete. While it covers diagnosis, it lacks the "Diagnostic procedures" necessary for the subsequent staging and management of the patient. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Never rely on a Pap smear if a visible growth is present; proceed directly to biopsy. * **Post-coital bleeding:** In a multiparous woman, this is considered cervical cancer until proven otherwise. * **Staging:** Cervical cancer is staged **clinically** (FIGO staging). * **Most common site:** The Squamocolumnar Junction (Transformation Zone).

Question 536: Point B in cervical radiotherapy represents which lymph node area?

A. Sentinel Lymph nodes
B. Internal iliac Lymph nodes
C. External iliac Lymph nodes
D. Obturator Lymph nodes (Correct Answer)

Explanation: In cervical cancer radiotherapy (Manchester System), **Point B** is a critical anatomical landmark used to assess the dose to the pelvic side walls and regional lymph nodes. ### **Explanation of the Correct Answer** Point B is located **2 cm superior** to the external cervical os and **5 cm lateral** to the midline (3 cm lateral to Point A). Anatomically, this point corresponds to the **obturator lymph nodes**, which are the primary drainage site for the cervix. It also represents the area where the uterine artery originates from the internal iliac artery and where the parametrium meets the pelvic side wall. Monitoring the dose at Point B is essential to ensure adequate treatment of the parametria and the first-tier lymph nodes while avoiding toxicity to the pelvic side wall structures. ### **Analysis of Incorrect Options** * **A. Sentinel Lymph nodes:** These are the first nodes to receive drainage (often the obturator or external iliac in the cervix), but Point B is a fixed geometric point, not a functional sentinel node definition. * **B. Internal iliac Lymph nodes:** While Point B is near the internal iliac vessels, it specifically aligns with the obturator group located in the obturator fossa. * **C. External iliac Lymph nodes:** These are located more laterally and superiorly along the pelvic brim, beyond the 5 cm lateral margin of Point B. ### **High-Yield Clinical Pearls for NEET-PG** * **Point A:** Located 2 cm superior to the external os and 2 cm lateral to the midline. It represents the crossing of the **uterine artery and the ureter**. It is the point where the dose is prescribed. * **Point B:** Located 5 cm lateral to the midline. It represents the **obturator nodes** and pelvic side wall. * **Rule of Thumb:** Point B dose is typically **1/3rd to 1/4th** of the dose at Point A. * **Mnemonic:** **A** is for **A**rtery (Uterine) and **B** is for **B**one/Wall (Pelvic side wall/Nodes).

Question 537: What is true about a hydatidiform mole?

A. It is always associated with a raised uterine size for gestational age.
B. It is associated with raised hCG levels. (Correct Answer)
C. Hysterectomy is indicated in selected cases.
D. Chemotherapy is the treatment of choice.

Explanation: **Explanation:** **Hydatidiform Mole (Gestational Trophoblastic Disease)** **1. Why Option B is correct:** Hydatidiform moles (both complete and partial) arise from the abnormal proliferation of trophoblastic tissue (syncytiotrophoblast and cytotrophoblast). Since the syncytiotrophoblast is responsible for the secretion of Human Chorionic Gonadotropin (hCG), its excessive proliferation leads to **markedly elevated serum hCG levels**, often exceeding 100,000 mIU/mL. This is a hallmark diagnostic feature. **2. Why other options are incorrect:** * **Option A:** While a "uterus larger than dates" is a classic sign of a **Complete Mole**, it is not universal. In **Partial Moles**, the uterine size is often small or appropriate for gestational age. * **Option C:** This is a tricky distractor. While hysterectomy can be considered in women >40 years who have completed their family to reduce the risk of choriocarcinoma, it is **not the standard management**. The primary treatment for a molar pregnancy is Suction and Evacuation (S&E). * **Option D:** Chemotherapy (usually Methotrexate) is the treatment of choice for **Gestational Trophoblastic Neoplasia (GTN)** (e.g., Choriocarcinoma or persistent mole), not for an uncomplicated hydatidiform mole. **High-Yield Clinical Pearls for NEET-PG:** * **Snowstorm Appearance:** Classic ultrasound finding in a complete mole. * **Theca Lutein Cysts:** Occur in 25-30% of cases due to high hCG levels (ovarian hyperstimulation). * **Karyotype:** Complete Mole is 46,XX (diploid, paternal origin); Partial Mole is 69,XXX/XXY (triploid). * **Follow-up:** Weekly hCG monitoring until three consecutive normal values are obtained to rule out malignancy.

Question 538: Pseudomyxoma peritonei occurs due to which of the following?

A. Mucinous cystadenocarcinoma of the ovary (Correct Answer)
B. Carcinoma of the colon
C. Adenoma of the stomach
D. Pancreatic adenocarcinoma

Explanation: **Explanation:** **Pseudomyxoma Peritonei (PMP)** is a clinical syndrome characterized by the accumulation of abundant gelatinous (mucinous) ascites within the peritoneal cavity, often referred to as "jelly belly." **Why Option A is Correct:** The condition most commonly arises from the rupture or leakage of a **mucinous tumor**. In gynecology, **Mucinous cystadenocarcinoma of the ovary** (or more frequently, a borderline mucinous tumor) is a classic cause. When these tumors rupture, mucin-secreting cells implant onto the peritoneal surfaces and continue to produce large amounts of mucus. **Analysis of Incorrect Options:** * **Option B & D:** While PMP can rarely be associated with other GI malignancies, the most common primary site is actually the **appendix** (mucocele or adenocarcinoma). Carcinoma of the colon and pancreatic adenocarcinoma are less frequent causes and do not typically present with the classic PMP syndrome compared to appendiceal or ovarian mucinous tumors. * **Option C:** Adenoma of the stomach is a benign mucosal lesion and does not typically lead to peritoneal seeding or the massive mucinous production characteristic of PMP. **NEET-PG High-Yield Pearls:** * **Primary Source:** Modern pathology suggests that most cases of PMP previously attributed to the ovary actually originate from a primary **appendiceal mucinous neoplasm** that secondarily involves the ovaries. * **Clinical Presentation:** Patients often present with increasing abdominal girth, "omental caking" on CT scans, and may mimic an inguinal hernia. * **Treatment:** The gold standard is **Cytoreductive Surgery (CRS)** combined with **Hyperthermic Intraperitoneal Chemotherapy (HIPEC)**, often called the "Sugarbaker procedure." * **Histology:** Look for "pools of extracellular mucin" containing sparse malignant or borderline epithelial cells.

Question 539: Meig's syndrome consists of the following except?

A. Ascites
B. Hydrothorax
C. Benign ovarian tumour
D. Malignant ovarian tumour (Correct Answer)

Explanation: **Explanation:** Meigs' syndrome is defined by a specific triad of clinical findings. The diagnosis is strictly reserved for cases involving a **benign ovarian tumor** (most commonly an **Ovarian Fibroma**) accompanied by **ascites** and **pleural effusion (hydrothorax)**. A key diagnostic criterion is that these symptoms must resolve completely following the surgical removal of the tumor. **Why "Malignant ovarian tumour" is the correct answer:** By definition, Meigs' syndrome involves only benign tumors. If a malignant ovarian tumor presents with ascites and pleural effusion, it is classified as advanced-stage ovarian cancer (Stage IV), not Meigs' syndrome. Therefore, Option D is the "except" as it does not fit the syndrome's definition. **Analysis of other options:** * **A. Ascites:** A core component of the triad. The fluid is thought to arise from the surface of the tumor or due to lymphatic obstruction. * **B. Hydrothorax:** Typically occurs on the **right side** (70% of cases). Fluid moves from the peritoneum to the pleural space through transdiaphragmatic lymphatics or small diaphragmatic defects. * **C. Benign ovarian tumour:** Essential for the diagnosis. While Fibroma is the most common, other benign tumors like Thecomas, Cystadenomas, or Granulosa cell tumors (if behaving benignly) can be involved. **NEET-PG High-Yield Pearls:** 1. **Pseudo-Meigs' Syndrome:** Occurs when the triad is associated with other pelvic masses (e.g., uterine leiomyomas, struma ovarii, or malignant tumors). 2. **Most Common Tumor:** Ovarian Fibroma (a sex cord-stromal tumor). 3. **Nature of Fluid:** Usually a transudate, but can be an exudate. 4. **Resolution:** The hallmark of the syndrome is the spontaneous disappearance of fluid after tumor excision.

Question 540: Snow storm appearance is seen in which of the following conditions?

A. Ectopic pregnancy
B. Molar pregnancy (Correct Answer)
C. Incomplete abortion
D. Heterotopic pregnancy

Explanation: **Explanation:** The "Snowstorm appearance" is a classic ultrasonographic hallmark of a **Molar Pregnancy** (Hydatidiform Mole). This appearance is caused by the presence of multiple hydropic (swollen) chorionic villi interspersed with areas of hemorrhage and blood clots. On ultrasound, these appear as numerous small, echo-free (anechoic) cystic spaces within a thickened, heterogeneous endometrial mass, resembling a blizzard or snowstorm. **Analysis of Options:** * **Molar Pregnancy (Correct):** The characteristic vesicular swelling of the villi creates the "snowstorm" or "bunch of grapes" appearance. In a complete mole, no fetal parts are visible. * **Ectopic Pregnancy:** Typically presents with an empty uterus, a pseudo-gestational sac, or an adnexal mass (often showing the "Ring of Fire" sign on Doppler). * **Incomplete Abortion:** Ultrasound usually shows irregular echogenic shadows within the uterine cavity representing retained products of conception (RPOC), but it lacks the uniform cystic pattern of a mole. * **Heterotopic Pregnancy:** This refers to the simultaneous existence of an intrauterine and an extrauterine pregnancy. It does not produce a snowstorm pattern. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Ultrasonography (USG) is the investigation of choice. * **Biochemical Marker:** Markedly elevated serum **β-hCG levels** (often >100,000 mIU/mL) are characteristic. * **Theca Lutein Cysts:** Often seen in the ovaries due to high hCG levels (hyperreactio luteinalis). * **Management:** Suction and evacuation is the treatment of choice, regardless of the size of the uterus. * **Histopathology:** The definitive diagnosis is confirmed by histopathological examination showing trophoblastic proliferation and villous edema.

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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