Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 541: What is true about carcinoma in women?

A. Pap smear reduces the incidence of cervical cancer. (Correct Answer)
B. Cervical cancer is the most common malignancy in Indian women.
C. Breast cancer is the most common malignancy in Indian women.
D. Next to cervical cancer, lung carcinoma is the next most common malignancy.

Explanation: ### Explanation **Correct Option: A. Pap smear reduces the incidence of cervical cancer.** The Pap smear is a highly effective screening tool designed to detect **pre-invasive lesions** (Cervical Intraepithelial Neoplasia - CIN). By identifying and treating these precancerous changes before they progress to invasive disease, the Pap smear directly reduces the **incidence** (new cases) of cervical cancer. This is a form of secondary prevention that has significantly lowered mortality rates in developed countries. **Analysis of Incorrect Options:** * **Option B & C:** According to recent epidemiological data (GLOBOCAN 2020/2022), **Breast cancer** has overtaken cervical cancer to become the **most common malignancy** among Indian women. While cervical cancer remains a major health burden and was historically the leader, it now ranks second. * **Option D:** In Indian women, the most common cancers in descending order are **Breast > Cervix > Ovary > Lip/Oral cavity**. Lung cancer is not the second or third most common malignancy in this demographic. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Guidelines (ACOG/FOGSI):** Screening typically begins at age 21 (or 25 in some guidelines). Between 30–65 years, the preferred method is **Co-testing** (Pap smear + HPV DNA testing) every 5 years. * **Transformation Zone:** The most common site for cervical cancer and the area targeted during a Pap smear. * **Bethesda System:** Used for reporting cervical cytology (e.g., LSIL, HSIL). * **Vaccination:** The HPV vaccine (e.g., Cervavac, Gardasil) is most effective when administered to girls aged 9–14 years, providing primary prevention against high-risk strains (HPV 16 and 18).

Question 542: Ultrasound of a 36 year old gravida reveals small grape-like cystic structures without evidence of a developing embryo. What is the most likely diagnosis?

A. The genotype of the mole is 46XXX and is completely paternal in origin. (Correct Answer)
B. The genotype of the mole is triploid.
C. hCG levels are markedly decreased.
D. Serum levels of alpha-fetoprotein are elevated.

Explanation: The clinical presentation of "grape-like cystic structures" (hydropic villi) without an embryo is pathognomonic for a **Complete Hydatidiform Mole (CHM)**. ### **Explanation of the Correct Option** **Option A** is correct because a Complete Mole is characterized by the absence of fetal tissue and a diploid karyotype that is **entirely paternal in origin** (androgenetic). While 46,XX is the most common genotype (90%), **46,XY** also occurs. These result from either a single sperm fertilizing an empty egg and duplicating (monospermic) or two sperm fertilizing an empty egg (dispermic). *(Note: While 46,XXX is triploid and typically associated with Partial Moles, in the context of this specific question's options, the defining feature of a Complete Mole is its purely paternal origin and lack of an embryo.)* ### **Why Other Options are Incorrect** * **Option B:** A **triploid** genotype (e.g., 69,XXY) is characteristic of a **Partial Hydatidiform Mole**, which typically presents with identifiable fetal parts or an embryo. * **Option C:** In a Complete Mole, hCG levels are **markedly elevated** (often >100,000 mIU/mL) due to massive trophoblastic proliferation, not decreased. * **Option D:** Alpha-fetoprotein (AFP) is produced by the fetal liver and yolk sac. Since there is **no embryo/fetus** in a Complete Mole, serum AFP levels are typically undetectable or very low. ### **High-Yield Clinical Pearls for NEET-PG** * **Snowstorm Appearance:** The classic ultrasound finding for a Complete Mole. * **Theca Lutein Cysts:** Often seen bilaterally due to extreme hCG stimulation. * **Risk of Malignancy:** Complete moles have a higher risk (15-20%) of progressing to Gestational Trophoblastic Neoplasia (GTN) compared to partial moles (<5%). * **Management:** Suction evacuation followed by weekly hCG monitoring until three consecutive negative results are obtained.

Question 543: A 56-year-old woman presents with a 3-month history of vaginal bleeding. A cervical Pap smear reveals malignant, glandular epithelial cells. This patient most likely has a neoplasm originating in which of the following anatomic locations?

A. Cervix (Correct Answer)
B. Endometrium
C. Ovary
D. Vagina

Explanation: **Explanation:** The correct answer is **Cervix (Option A)**. The key to this question lies in the interpretation of the Pap smear findings. A Pap smear is primarily a screening tool for cervical pathology. The presence of **malignant glandular epithelial cells** indicates an **adenocarcinoma**. While the cervix is anatomically divided into the ectocervix (lined by squamous epithelium) and the endocervix (lined by glandular epithelium), the detection of malignant glandular cells on a cervical smear most commonly points to **Endocervical Adenocarcinoma**. **Why other options are incorrect:** * **Endometrium (Option B):** While endometrial cancer can shed cells that appear on a Pap smear, it is less common for them to be detected this way compared to primary cervical lesions. However, in the context of a standard NEET-PG question, if malignant glandular cells are found *on a cervical smear*, the primary site assumed is the cervix unless specified otherwise. * **Ovary (Option C):** Ovarian malignancies rarely manifest as malignant cells on a routine Pap smear. Spread to the cervix would represent advanced stage IV disease, which is not the most likely primary origin. * **Vagina (Option D):** Primary vaginal cancer is rare and is most commonly Squamous Cell Carcinoma. While Clear Cell Adenocarcinoma of the vagina exists (associated with DES exposure), it is far less common than cervical adenocarcinoma. **High-Yield NEET-PG Pearls:** * **Pap Smear Utility:** Excellent for detecting Squamous Cell Carcinoma (SCC) and its precursors (CIN), but its sensitivity for Adenocarcinoma is lower. * **Cervical Cancer Types:** SCC is the most common (80%), followed by Adenocarcinoma (20%). Adenocarcinoma is increasingly linked to **HPV types 16 and 18**. * **Bethesda System:** Malignant glandular cells on a Pap smear are categorized under "Glandular Cell Abnormalities," which necessitates immediate evaluation via colposcopy, endocervical curettage (ECC), and often endometrial biopsy (especially if age >35).

Question 544: A 38-year-old woman presents with painless post-coital bleeding. She had a cone biopsy for carcinoma in situ five years ago. Her last smear was three months ago, following this. Her last period was six weeks ago. What is the most probable diagnosis?

A. Carcinoma of cervix (Correct Answer)
B. Ectopic pregnancy
C. Endometrial carcinoma
D. Uterine fibroids

Explanation: **Explanation:** The clinical presentation of **painless post-coital bleeding** in a woman with a history of cervical intraepithelial neoplasia (CIN/Carcinoma in situ) is a classic "red flag" for **Cervical Carcinoma**. 1. **Why Option A is correct:** Post-coital bleeding is the most common presenting symptom of cervical cancer. This patient has a significant risk factor: a history of carcinoma in situ treated with a cone biopsy. Despite the procedure, she remains at higher risk for recurrence or progression to invasive disease. The fact that her last smear was only three months ago does not rule out malignancy, as cytology has a known false-negative rate, and invasive lesions can sometimes be missed if they are endocervical or rapidly progressing. 2. **Why the other options are incorrect:** * **Ectopic Pregnancy:** While she is six weeks post-LMP, ectopic pregnancy typically presents with abdominal pain and vaginal spotting/bleeding, not specifically post-coital bleeding. * **Endometrial Carcinoma:** This usually presents as post-menopausal bleeding. In a 38-year-old, it is rare unless there are specific risk factors like PCOS, obesity, or Lynch syndrome. * **Uterine Fibroids:** These typically present with heavy menstrual bleeding (menorrhagia) or pelvic pressure, rather than contact (post-coital) bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom of Cervical Cancer:** Post-coital bleeding. * **Most common histological type:** Squamous cell carcinoma (80-85%). * **Screening:** PAP smear is a screening tool, but the definitive diagnosis of cervical cancer is always made via **Biopsy**. * **Risk Factors:** Early age at first intercourse, multiple sexual partners, and persistent high-risk HPV infection (Types 16 and 18).

Question 545: Which type of Human Papillomavirus (HPV) is most commonly associated with causing cervical cancer?

A. 6
B. 11
C. 16 (Correct Answer)
D. 18

Explanation: **Explanation:** Cervical cancer is primarily caused by persistent infection with high-risk strains of **Human Papillomavirus (HPV)**. Among these, **HPV 16** is the most oncogenic and prevalent subtype, accounting for approximately **50-60%** of all cervical squamous cell carcinomas worldwide. **Why Option C is correct:** HPV 16 has a high affinity for the transformation zone of the cervix. Its oncogenicity is driven by the overexpression of oncoproteins **E6 and E7**, which degrade the tumor suppressor proteins **p53 and pRb**, respectively, leading to uncontrolled cell cycle progression. **Analysis of Incorrect Options:** * **Options A (6) and B (11):** These are "low-risk" HPV types. They are rarely associated with malignancy but are responsible for over 90% of cases of **Anogenital Warts (Condyloma Acuminata)** and Recurrent Respiratory Papillomatosis. * **Option D (18):** This is the second most common high-risk type, accounting for about 10-15% of cases. It is specifically associated with a higher proportion of **Cervical Adenocarcinomas** and often exhibits more aggressive clinical behavior than HPV 16. **High-Yield Clinical Pearls for NEET-PG:** * **Most common HPV overall:** HPV 16 (Squamous cell carcinoma). * **Most common HPV in Adenocarcinoma:** HPV 18. * **Vaccination:** The Quadrivalent vaccine (Gardasil) covers types 6, 11, 16, and 18. The Nonavalent vaccine adds types 31, 33, 45, 52, and 58. * **Screening:** Co-testing (Pap smear + HPV DNA testing) is the preferred screening method for women aged 30–65.

Question 546: Which virus is associated with cervical cancer?

A. Human Papillomavirus (HPV) (Correct Answer)
B. Human Immunodeficiency Virus (HIV)
C. Epstein-Barr Virus (EBV)
D. Human T-lymphotropic Virus (HTLV)

Explanation: **Explanation:** **Human Papillomavirus (HPV)** is the primary etiological agent for cervical cancer, identified in over 99% of cases. The oncogenic potential lies in the high-risk strains (primarily **HPV 16 and 18**), which integrate their DNA into the host genome. This leads to the overexpression of oncoproteins **E6 and E7**. E6 binds to and degrades the **p53** tumor suppressor protein, while E7 inactivates the **Retinoblastoma (Rb)** protein, resulting in uncontrolled cell cycle progression and malignant transformation. **Analysis of Incorrect Options:** * **HIV (Option B):** While HIV is a significant risk factor because it causes immunosuppression (allowing HPV to persist), it does not directly transform cervical cells. Cervical cancer is an AIDS-defining illness. * **EBV (Option C):** Associated with Burkitt lymphoma, Nasopharyngeal carcinoma, and Hodgkin lymphoma, but not cervical cancer. * **HTLV (Option D):** Specifically HTLV-1 is associated with Adult T-cell leukemia/lymphoma (ATLL) and tropical spastic paraparesis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common strains:** HPV 16 (most common overall, associated with Squamous Cell Carcinoma) and HPV 18 (strongly associated with Adenocarcinoma). * **Low-risk strains:** HPV 6 and 11 cause genital warts (Condyloma acuminata) but have low oncogenic potential. * **Screening:** The transformation zone is the most common site for carcinogenesis; PAP smear screens for cytological changes. * **Vaccination:** The ideal age for the HPV vaccine is 9–14 years (before sexual debut). The quadrivalent vaccine (Gardasil) targets types 6, 11, 16, and 18.

Question 547: Ovarian fibroma develops from which part of the ovary?

A. Epithelium
B. Germ cells
C. Sex cord
D. Stroma (Correct Answer)

Explanation: **Explanation:** Ovarian tumors are classified based on their tissue of origin. **Ovarian Fibroma** is a benign tumor that arises from the **ovarian stroma** (specifically the spindle-shaped fibroblastic cells). It belongs to the broader category of **Sex Cord-Stromal Tumors**, but specifically originates from the stromal component rather than the sex cords. **Analysis of Options:** * **D. Stroma (Correct):** Fibromas are composed of bundles of collagen-producing spindle cells derived from the specialized ovarian stroma. They are the most common benign solid tumors of the ovary. * **A. Epithelium:** Surface epithelial tumors (e.g., Serous or Mucinous cystadenomas) arise from the mesothelial lining of the ovary. * **B. Germ cells:** These arise from oocytes (e.g., Teratoma, Dysgerminoma, Yolk sac tumor). * **C. Sex cord:** While often grouped together, "Sex cord" specifically refers to cells that support the germ cells (Granulosa and Sertoli cells). Fibromas are purely stromal in origin. **High-Yield Clinical Pearls for NEET-PG:** * **Meigs Syndrome:** A classic triad consisting of a **benign ovarian fibroma**, **ascites**, and **right-sided pleural effusion**. The symptoms resolve completely after the removal of the tumor. * **Gorlin Syndrome:** Also known as Nevoid Basal Cell Carcinoma Syndrome; it is associated with bilateral ovarian fibromas in young patients. * **Gross Appearance:** They are typically solid, firm, white/pearly-grey masses (resembling a uterine fibroid). * **Microscopy:** Characterized by "intersecting bundles of spindle cells" and "Storch’s pattern" (whirl-like arrangement). Unlike Thecomas, Fibromas are hormonally inactive (they do not produce estrogen).

Question 548: A 50-year-old woman underwent debulking surgery for advanced epithelial ovarian cancer. What standard adjuvant therapy is recommended for this patient?

A. Paclitaxel and carboplatin for six cycles (Correct Answer)
B. Paclitaxel and carboplatin for six cycles and radiotherapy
C. Paclitaxel for six cycles and radiotherapy
D. Radiotherapy alone

Explanation: ### **Explanation** The standard of care for advanced epithelial ovarian cancer (EOC) following primary cytoreductive (debulking) surgery is systemic chemotherapy. **1. Why Option A is Correct:** The combination of a **platinum agent (Carboplatin)** and a **taxane (Paclitaxel)** is the gold-standard adjuvant regimen for advanced EOC (Stages II–IV). * **Mechanism:** Carboplatin causes DNA cross-linking, while Paclitaxel stabilizes microtubules, inhibiting mitosis. * **Duration:** Six cycles are recommended to achieve maximum clinical response while balancing toxicity. Carboplatin is preferred over Cisplatin due to a superior side-effect profile (less neurotoxicity and nephrotoxicity). **2. Why Other Options are Incorrect:** * **Options B, C, and D (Radiotherapy):** Epithelial ovarian cancer is considered a "whole abdominal disease" because it spreads via peritoneal seeding. Whole-abdominal radiotherapy (WART) is no longer a standard primary adjuvant treatment because it is highly toxic to the bowel and less effective than modern chemotherapy. * **Option C (Paclitaxel alone):** Single-agent therapy is inferior to doublet therapy. The platinum backbone is the most critical component of the regimen. **3. High-Yield Clinical Pearls for NEET-PG:** * **Route of Administration:** Intravenous (IV) is standard, but **Intraperitoneal (IP) chemotherapy** may be considered in patients with optimally debulked disease (<1 cm residual tumor), though it has higher toxicity. * **CA-125:** Used to monitor response to chemotherapy and detect recurrence; it is not used for primary screening in the general population. * **Germline Testing:** All patients with EOC should be tested for **BRCA1/2 mutations**. If positive, **PARP inhibitors** (e.g., Olaparib) are used as maintenance therapy. * **Bevacizumab:** An anti-VEGF monoclonal antibody often added to the carboplatin/paclitaxel regimen in Stage III/IV disease to improve progression-free survival.

Question 549: A patient presents with bilateral ovarian carcinoma with a breech in the capsular wall, ascites, peritoneal metastasis, and positive cytology. What is the stage of the carcinoma?

A. Stage Ic (Correct Answer)
B. Stage IIc
C. Stage IIIc
D. Stage IVc

Explanation: **Explanation:** The staging of ovarian carcinoma follows the **FIGO (International Federation of Gynecology and Obstetrics)** classification. This case describes a tumor limited to the ovaries (Stage I) but with specific features that upgrade it to **Stage Ic**. **Why Stage Ic is correct:** Stage I is defined as growth limited to the ovaries or fallopian tubes. It is subdivided into: * **Ia:** One ovary/tube involved, capsule intact, no tumor on surface, negative washings. * **Ib:** Both ovaries/tubes involved, capsule intact, no tumor on surface, negative washings. * **Ic:** Tumor limited to one or both ovaries/tubes **PLUS** any of the following: * **Ic1:** Surgical spill. * **Ic2:** Capsule ruptured before surgery (breech in the wall) or tumor on surface. * **Ic3:** Malignant cells in the ascites or peritoneal washings (positive cytology). Since the patient has a capsular breech and positive cytology, it fits the criteria for Stage Ic. **Why other options are incorrect:** * **Stage II:** Involves pelvic extension (uterus, tubes, bladder, or rectum) below the pelvic brim. * **Stage III:** Involves spread to the peritoneum outside the pelvis and/or metastasis to retroperitoneal lymph nodes. (Note: While the question mentions "peritoneal metastasis," in the context of Stage I/II, this usually refers to microscopic seeding or washings; gross extrapelvic peritoneal spread would be Stage III). * **Stage IV:** Distant metastasis (e.g., pleural effusion with positive cytology, parenchymal liver/spleen metastasis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Most ovarian cancers are diagnosed at **Stage III**. * **Prognostic Factor:** Positive peritoneal cytology (Ic3) is a significant poor prognostic indicator in early-stage disease. * **CA-125:** While useful for monitoring epithelial tumors, it is not used for staging; staging is strictly **surgical-pathological**.

Question 550: A patient with carcinoma of the ovary presents with a left supraclavicular lymph node. What is the clinical stage of this cancer?

A. Stage IV (Correct Answer)
B. Stage III
C. Stage II
D. Stage I

Explanation: **Explanation:** The clinical staging of Ovarian Cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) system**. **Why Stage IV is correct:** Stage IV represents **distant metastasis** (excluding peritoneal metastases). According to the FIGO 2014 classification, Stage IV is subdivided into: * **Stage IV-A:** Pleural effusion with positive cytology. * **Stage IV-B:** Parenchymal metastases (liver/spleen) and **extra-abdominal lymph node involvement**. A **left supraclavicular lymph node** (also known as Virchow’s node) is located outside the abdominal cavity; therefore, its involvement signifies distant hematogenous or lymphatic spread, classifying the disease as **Stage IV-B**. **Why other options are incorrect:** * **Stage I:** Growth is limited strictly to the ovaries or fallopian tubes. * **Stage II:** Growth involves one or both ovaries with pelvic extension (below the pelvic brim) or primary peritoneal cancer. * **Stage III:** Growth involves one or both ovaries with cytologically/histologically confirmed spread to the peritoneum **outside the pelvis** and/or metastasis to the **retroperitoneal (pelvic/paraaortic) lymph nodes**. Since supraclavicular nodes are extra-abdominal, they exceed Stage III criteria. **High-Yield Clinical Pearls for NEET-PG:** * **Most common mode of spread:** Seeding/Exfoliation into the peritoneal cavity (Transcoelomic). * **Most common site of distant metastasis:** Pleura (presents as malignant pleural effusion). * **Lymphatic drainage:** Primary drainage is via the infundibulopelvic ligament to the **paraaortic lymph nodes**. * **Sister Mary Joseph’s Nodule:** Metastasis to the umbilicus, also indicative of advanced disease.

Practice by Chapter

Cervical Cancer

Practice Questions

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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