Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 551: Which of the following gynaecological cancers is unusual in young women?

A. Cancer ovary
B. Cancer cervix
C. Cancer vulva (Correct Answer)
D. Choriocarcinoma

Explanation: **Explanation:** **Cancer of the vulva** is primarily a disease of elderly, postmenopausal women. The peak incidence occurs in the **7th and 8th decades of life** (average age 65–70 years). The most common histological type, Keratinizing Squamous Cell Carcinoma, is typically associated with lichen sclerosus and chronic inflammatory conditions seen in older age groups. While HPV-related vulvar intraepithelial neoplasia (VIN) can occur in younger women, progression to invasive cancer in this demographic remains rare compared to other gynecological malignancies. **Analysis of Incorrect Options:** * **Cancer Ovary:** While common in older women, specific types like **Germ Cell Tumors** (e.g., Dysgerminoma, Yolk sac tumor) are most prevalent in adolescents and women in their 20s. * **Cancer Cervix:** This is the most common gynecological cancer in many developing regions and frequently affects women in their **30s and 40s** due to early exposure to HPV. * **Choriocarcinoma:** This is a gestational trophoblastic neoplasia that occurs during the **reproductive years**, following a molar pregnancy, abortion, or normal term delivery. It is virtually unseen after menopause. **Clinical Pearls for NEET-PG:** * **Most common site for Vulvar Cancer:** Labia majora (anterior two-thirds). * **Most common histology:** Squamous cell carcinoma (90%). * **Lymphatic Spread:** Vulvar cancer spreads primarily via the lymphatics to the **Inguinal nodes** (Sentinel node) first, then to Femoral and Iliac nodes. * **Younger patients:** When vulvar cancer does occur in young women, it is almost always associated with **High-risk HPV (16, 18)** and smoking.

Question 552: A 54-year-old woman undergoes a laparotomy for a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered with a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. What is the most appropriate intraoperative course of action?

A. Excision of the omental metastasis and ovarian cystectomy
B. Omentectomy and ovarian cystectomy
C. Excision of the omental metastasis and unilateral oophorectomy
D. Omentectomy, total abdominal hysterectomy, and bilateral salpingo oophorectomy (Correct Answer)

Explanation: ### Explanation **Core Concept: Surgical Management of Epithelial Ovarian Cancer (EOC)** The primary management for suspected or confirmed epithelial ovarian cancer (like serous cystadenocarcinoma) is **comprehensive surgical staging and cytoreduction (debulking)**. In a postmenopausal woman (54 years old) with evidence of metastatic disease (omental spread), the goal is to remove all visible tumor deposits and the primary source. The standard procedure for ovarian cancer includes: 1. **Total Abdominal Hysterectomy (TAH)** 2. **Bilateral Salpingo-Oophorectomy (BSO)** 3. **Infracolic Omentectomy** 4. Peritoneal washings, pelvic/para-aortic lymphadenectomy, and peritoneal biopsies. **Why the Correct Answer is Right:** Option D is the only choice that follows the oncological principle of maximal cytoreduction. Since the patient has metastatic serous cystadenocarcinoma, leaving the uterus or the contralateral ovary would leave behind potential microscopic disease and fail to achieve optimal debulking, which is the strongest predictor of survival. **Why Incorrect Options are Wrong:** * **Options A & B:** "Ovarian cystectomy" is contraindicated in suspected malignancy as it risks spilling tumor cells into the peritoneal cavity and is oncologically inadequate. * **Option C:** Unilateral oophorectomy is only considered in very early-stage (Stage IA) disease in young patients wishing to preserve fertility. In a 54-year-old with omental metastasis, this is insufficient. **NEET-PG High-Yield Pearls:** * **Most common type of Ovarian Cancer:** Serous cystadenocarcinoma (often presents at advanced stages). * **Tumor Marker:** CA-125 is the most common marker for epithelial ovarian tumors. * **Optimal Debulking:** Defined as residual disease <1 cm in maximum diameter (ideally no visible disease). * **Staging:** Ovarian cancer is staged **surgically** (FIGO staging). The presence of omental metastasis >2 cm indicates at least Stage IIIC.

Question 553: A 40-year-old P4+2 female has been diagnosed with hydatidiform mole. What is the appropriate treatment?

A. Radiotherapy
B. Chemotherapy
C. Total hysterectomy (Correct Answer)
D. Combined Radio-Chemotherapy

Explanation: **Explanation:** The management of a hydatidiform mole is primarily determined by the patient's age and desire for future fertility. **Why Total Hysterectomy is correct:** While **Suction Evacuation** is the standard treatment for most cases of molar pregnancy, **Total Hysterectomy** is the preferred treatment in this specific scenario. The patient is 40 years old and multiparous (P4+2), indicating she has likely completed her family. In women over 40, the risk of developing **Gestational Trophoblastic Neoplasia (GTN)** or choriocarcinoma following a molar pregnancy increases significantly (up to 30-50%). Hysterectomy eliminates the local risk of malignancy and provides a definitive cure while bypassing the need for potential repeat evacuations. Note: The ovaries are typically preserved as the theca lutein cysts will regress spontaneously. **Why other options are incorrect:** * **Radiotherapy (A & D):** Gestational trophoblastic diseases are highly radiosensitive, but radiation is not used for primary management. It is reserved for specific metastatic sites (e.g., brain or liver) in malignant GTN. * **Chemotherapy (B):** Prophylactic chemotherapy is generally not recommended for benign hydatidiform moles. Chemotherapy (e.g., Methotrexate) is the mainstay for **malignant** GTN (Invasive mole/Choriocarcinoma), not the initial treatment for a benign mole. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Pelvic Ultrasound showing a "Snowstorm appearance." * **Standard Treatment:** Suction Evacuation (regardless of uterine size) for those wanting to preserve fertility. * **Follow-up:** Weekly serum β-hCG levels until three consecutive negatives, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (COCs) are the preferred method during follow-up once hCG levels normalize.

Question 554: A 20-year-old woman presents with rapid onset hirsutism and a pelvic mass. What is the likely cause?

A. Sex cord-stromal tumor of the ovary (Correct Answer)
B. Polycystic ovarian syndrome
C. Congenital adrenal hyperplasia
D. Large simple ovarian cyst

Explanation: ### Explanation **Correct Answer: A. Sex cord-stromal tumor of the ovary** The key clinical markers in this case are **rapid onset virilization** (hirsutism) and the presence of a **pelvic mass**. In a young woman, this combination is a classic presentation for a virilizing sex cord-stromal tumor, most commonly a **Sertoli-Leydig cell tumor**. These tumors produce high levels of testosterone, leading to sudden defeminization followed by masculinization. **Why other options are incorrect:** * **B. Polycystic Ovarian Syndrome (PCOS):** While PCOS is a common cause of hirsutism, it typically presents with a **gradual onset** starting at puberty and is associated with bilateral "necklace" appearance of follicles, not a large, discrete pelvic mass. * **C. Congenital Adrenal Hyperplasia (CAH):** This is a systemic enzymatic deficiency (usually 21-hydroxylase). While it causes virilization, it presents with bilateral adrenal hyperplasia rather than a palpable pelvic mass. * **D. Large simple ovarian cyst:** Simple cysts are usually functional (follicular or luteal) and do not possess the endocrine machinery to produce androgens; they are typically asymptomatic or cause pressure symptoms. **Clinical Pearls for NEET-PG:** * **Sertoli-Leydig Cell Tumor:** The most common virilizing ovarian tumor. Look for elevated **Testosterone** levels (>200 ng/dL). * **Reinke Crystals:** Pathognomonic histological finding in Leydig cell tumors. * **Rule of Thumb:** Rapid onset virilization + Pelvic mass = Ovarian origin (Sertoli-Leydig). Rapid onset virilization + No pelvic mass = Adrenal origin (check DHEAS). * **Tumor Marker:** Inhibin is often elevated in sex cord-stromal tumors (especially Granulosa cell tumors).

Question 555: Which of the investigations is/are used for the diagnosis of hydatidiform mole?

A. HCG titer
B. USG
C. Chest x-ray
D. All of the above (Correct Answer)

Explanation: Hydatidiform mole (molar pregnancy) is a type of Gestational Trophoblastic Disease (GTD) characterized by abnormal proliferation of trophoblastic tissue. The diagnosis relies on a combination of clinical suspicion, biochemical markers, and imaging. **Explanation of the Correct Answer:** * **HCG Titer (Option A):** Serum β-hCG levels are disproportionately high for the gestational age (often >100,000 mIU/mL). It is the primary biochemical marker used for both diagnosis and post-evacuation follow-up. * **USG (Option B):** Ultrasonography is the **investigation of choice**. In a complete mole, it reveals a characteristic **"Snowstorm appearance"** (echogenic mass with multiple small cystic spaces) and the absence of a fetus. * **Chest X-ray (Option C):** While not used to diagnose the molar pregnancy itself, it is a mandatory part of the initial diagnostic workup to rule out pulmonary metastasis (trophoblastic embolization), which occurs even in benign moles. Since all three investigations are integral to the initial evaluation and staging of a suspected molar pregnancy, **Option D (All of the above)** is correct. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Histopathological examination (HPE) after suction evacuation. * **Theca Lutein Cysts:** Often seen on USG due to high hCG levels (bilateral, multiloculated). * **Partial vs. Complete Mole:** Complete moles are 46,XX (paternal origin), while partial moles are 69,XXX/XXY (triploidy). * **Management:** Suction and evacuation is the treatment of choice regardless of uterine size. * **Follow-up:** Weekly β-hCG until three consecutive negative results, then monthly for 6 months. Pregnancy must be avoided during this period.

Question 556: What is the most common type of ovarian tumor?

A. Dermoid
B. Cystadenoma (Correct Answer)
C. Fibroma
D. Cystadenocarcinoma

Explanation: **Explanation:** Ovarian tumors are classified based on their tissue of origin: Surface Epithelial, Germ Cell, Sex Cord-Stromal, and Metastatic. **Surface epithelial tumors** are the most common category, accounting for approximately 60–70% of all ovarian neoplasms. **Why Cystadenoma is correct:** Cystadenomas (specifically Serous and Mucinous) are benign surface epithelial tumors. In clinical practice, **benign tumors** are far more common than malignant ones (80% vs. 20%). Among all ovarian neoplasms, the **Serous Cystadenoma** is the single most common type. **Analysis of Incorrect Options:** * **A. Dermoid (Mature Cystic Teratoma):** This is a germ cell tumor. While it is the most common ovarian tumor in **young women (ages 20–30)**, it is less frequent than epithelial cystadenomas when considering all age groups. * **C. Fibroma:** This is a sex cord-stromal tumor. It is the most common solid benign tumor of the ovary but is relatively rare compared to epithelial cysts. It is classically associated with Meigs’ Syndrome. * **D. Cystadenocarcinoma:** This is the malignant counterpart of cystadenomas. While Serous Cystadenocarcinoma is the most common **malignant** ovarian tumor, benign cystadenomas occur much more frequently in the general population. **NEET-PG High-Yield Pearls:** * **Most common ovarian neoplasm overall:** Serous Cystadenoma. * **Most common malignant ovarian tumor:** Serous Cystadenocarcinoma. * **Most common tumor in children/adolescents:** Germ cell tumors (specifically Dermoid). * **Most common bilateral ovarian tumor:** Serous Cystadenoma/Carcinoma (Krukenberg is also frequently bilateral but is metastatic). * **Psammoma bodies** are a characteristic histological finding in Serous tumors.

Question 557: What is the investigation of choice in a 55-year-old postmenopausal woman presenting with postmenopausal bleeding?

A. Pap smear
B. Fractional curettage (Correct Answer)
C. Transvaginal ultrasound
D. CA-125

Explanation: **Explanation:** In a postmenopausal woman presenting with bleeding, the primary clinical objective is to rule out **Endometrial Carcinoma**, which is present in approximately 10% of such cases. **Why Fractional Curettage is the Correct Choice:** Fractional curettage is traditionally considered the "gold standard" investigation of choice for postmenopausal bleeding. It involves two steps: first, sampling the endocervical canal, and second, the endometrium. This allows the clinician to differentiate between primary endometrial cancer and cervical cancer extending upwards. Histopathological examination of the tissue obtained provides a definitive diagnosis, which is mandatory before planning management. **Analysis of Incorrect Options:** * **A. Pap smear:** This is a screening tool for cervical cancer, not a diagnostic tool for endometrial pathology. While it may occasionally show glandular cells, it has very low sensitivity for detecting endometrial cancer. * **C. Transvaginal Ultrasound (TVS):** TVS is an excellent initial **screening** tool. An endometrial thickness (ET) of ≤4 mm has a high negative predictive value. However, if the ET is >4 mm or if bleeding persists, a tissue diagnosis (like fractional curettage or Pipelle biopsy) is required for a definitive diagnosis. * **D. CA-125:** This is a tumor marker primarily used for monitoring epithelial ovarian cancer. It is neither sensitive nor specific for diagnosing postmenopausal bleeding. **NEET-PG High-Yield Pearls:** * **Most common cause** of postmenopausal bleeding: **Senile Atrophic Vaginitis**. * **Most common malignancy** presenting as postmenopausal bleeding: **Endometrial Carcinoma**. * **Investigation of choice (Gold Standard):** Fractional Curettage (or Hysteroscopy-guided biopsy). * **First-line screening tool:** Transvaginal Ultrasound (Cut-off for biopsy: ET >4 mm).

Question 558: Molar pregnancy is diagnosed in which trimester?

A. First trimester (Correct Answer)
B. Second trimester
C. Third trimester
D. All of the above

Explanation: **Explanation:** **1. Why the First Trimester is Correct:** Historically, molar pregnancies (Hydatidiform mole) were often diagnosed in the second trimester due to delayed presentation of symptoms like "grape-like vesicles." However, with the advent of **routine high-resolution transvaginal ultrasonography (TVUS)** and highly sensitive **quantitative β-hCG assays**, the vast majority of cases are now diagnosed in the **first trimester (usually between 8–12 weeks).** Early diagnosis is characterized by the absence of a fetal pole and the classic "snowstorm appearance" on ultrasound, alongside β-hCG levels that are disproportionately high for gestational age. **2. Why the Other Options are Incorrect:** * **Second Trimester:** While diagnosis can occur here if prenatal care is delayed, it is no longer the standard time of detection. Waiting until the second trimester increases the risk of complications like pre-eclampsia (occurring before 20 weeks), hyperemesis gravidarum, and theca lutein cysts. * **Third Trimester:** It is extremely rare for a molar pregnancy to persist into the third trimester without causing life-threatening hemorrhage or being detected earlier due to the lack of fetal movement and heart tones. * **All of the Above:** Incorrect because the clinical goal and modern diagnostic standard focus specifically on early first-trimester detection to prevent morbidity. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Ultrasound (Snowstorm/Swiss-cheese appearance). * **Most Common Symptom:** Vaginal bleeding (painless). * **Karyotype:** Complete Mole is **46,XX** (diploid, paternal origin); Partial Mole is **69,XXX/XXY** (triploid). * **Clinical Sign:** Uterine size is often "greater than dates" in complete moles. * **Management:** Suction and Evacuation (S&E) is the treatment of choice, followed by weekly β-hCG monitoring until three consecutive negative results are obtained.

Question 559: A case of Gestational trophoblastic neoplasia belongs to the high-risk group if the disease develops after which type of pregnancy complication?

A. Hydatidiform mole
B. Full-term pregnancy (Correct Answer)
C. Spontaneous abortion
D. Ectopic pregnancy abortion

Explanation: **Explanation:** The classification of Gestational Trophoblastic Neoplasia (GTN) into low-risk and high-risk groups is primarily based on the **FIGO/WHO Scoring System**. One of the critical prognostic factors in this system is the **antecedent pregnancy**. **Why Full-term Pregnancy is the Correct Answer:** According to the FIGO scoring criteria, the type of preceding pregnancy significantly impacts the prognosis and risk score: * **Hydatidiform Mole:** Assigned a score of **0**. * **Abortion (Spontaneous/Induced) or Ectopic:** Assigned a score of **1**. * **Full-term Pregnancy:** Assigned a score of **2**. GTN following a full-term pregnancy is almost always **Choriocarcinoma**. These cases are associated with a higher tumor burden, delayed diagnosis (as symptoms like postpartum bleeding may be attributed to other causes), and a higher likelihood of chemoresistance and metastasis. Therefore, it is a major criteria for categorizing a patient into the high-risk group (Total FIGO score ≥7). **Analysis of Incorrect Options:** * **A. Hydatidiform mole:** This is the most common precursor to GTN (specifically Invasive Mole), but it carries the best prognosis and the lowest risk score (0). * **C & D. Spontaneous abortion / Ectopic pregnancy:** These are considered intermediate risk factors and are assigned a score of 1. They are less likely to result in high-risk GTN compared to a term pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Scoring:** A score of **0-6** is Low Risk (treated with single-agent chemotherapy, e.g., Methotrexate); a score of **≥7** is High Risk (requires multi-agent chemotherapy, e.g., EMA-CO). * **Most common site of metastasis:** Lungs (80%), followed by the Vagina (30%). * **Pathognomonic feature of Choriocarcinoma:** Absence of chorionic villi on histopathology (only sheets of syncytiotrophoblasts and cytotrophoblasts).

Question 560: Which of the following is NOT true about borderline ovarian tumors?

A. Approximately 10% of epithelial tumors of the ovary are classified as borderline tumors.
B. They have a high rate of recurrence following surgery. (Correct Answer)
C. They are well-differentiated tumors.
D. They do not invade the basement membrane.

Explanation: **Explanation:** Borderline Ovarian Tumors (BOTs), also known as "Tumors of Low Malignant Potential" (LMP), occupy an intermediate position between benign cystadenomas and invasive carcinomas. **Why Option B is the correct answer (False statement):** Contrary to invasive ovarian cancer, borderline tumors have an **excellent prognosis** and a **low rate of recurrence**. Most patients (approx. 75%) are diagnosed at Stage I. Even in cases of recurrence, the tumors usually remain borderline in histology rather than transforming into invasive carcinoma. The 10-year survival rate for Stage I BOTs is nearly 95-99%. **Analysis of other options:** * **Option A:** It is a standard epidemiological fact that approximately **10–15%** of all epithelial ovarian tumors are classified as borderline. * **Option C:** Histologically, these tumors are **well-differentiated**. They exhibit epithelial proliferation and nuclear atypia (stratification, pleomorphism) but lack the aggressive features of high-grade malignancies. * **Option D:** The hallmark histological feature that distinguishes a borderline tumor from a malignant one is the **absence of destructive stromal invasion** (they do not breach the basement membrane). **Clinical Pearls for NEET-PG:** * **Age Group:** BOTs typically occur in younger women (mean age 40–45 years) compared to invasive ovarian cancer. * **Management:** Fertility-sparing surgery (unilateral salpingo-oophorectomy or cystectomy) is the treatment of choice for young patients. * **CA-125:** May be elevated but is less specific than in invasive types. * **Most Common Type:** Serous borderline tumors are the most frequent, followed by mucinous. * **Psammoma bodies:** Frequently seen in serous borderline tumors.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

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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