Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 561: What is the percentage of complete moles that progress to persistent Gestational Trophoblastic Neoplasia (GTN)?

A. 1-4%
B. 4-8%
C. 8-12%
D. 15-20% (Correct Answer)

Explanation: **Explanation:** Gestational Trophoblastic Neoplasia (GTN) refers to the malignant subset of gestational trophoblastic diseases. The risk of malignant transformation is significantly higher in complete hydatidiform moles compared to partial moles. **Why 15-20% is correct:** In a **Complete Hydatidiform Mole (CHM)**, there is a total absence of fetal tissue and a 46,XX or 46,XY diploid karyotype (entirely paternal). Due to the higher proliferation of trophoblastic tissue, approximately **15-20%** of patients with a complete mole will develop persistent GTN (most commonly invasive mole, and less frequently, choriocarcinoma). **Analysis of Incorrect Options:** * **A, B, and C (1-12%):** These percentages are too low for complete moles. However, it is important to note that for **Partial Hydatidiform Moles (PHM)**, the risk of progression to GTN is much lower, typically cited as **1-5%**. Options A and B would be more representative of the risk associated with partial moles. **High-Yield Clinical Pearls for NEET-PG:** * **Karyotype:** Complete Mole is 46,XX (90%) or 46,XY (10%); Partial Mole is Triploid (69,XXX or 69,XXY). * **Risk Factors for Malignancy in CHM:** Pre-evacuation hCG >100,000 mIU/mL, excessive uterine size for dates, and large theca lutein cysts (>6 cm). * **Follow-up:** Post-evacuation, weekly β-hCG levels are monitored until three consecutive normal values are obtained, then monthly for 6 months. * **Diagnosis of GTN:** Based on FIGO criteria—hCG plateau (4 values over 3 weeks), hCG rise (3 values over 2 weeks), or histological diagnosis of choriocarcinoma.

Question 562: 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 (Correct Answer)
B. Hysterectomy and bilateral salpingo-oophorectomy
C. Hysterectomy with radiotherapy
D. Radiotherapy

Explanation: ### Explanation The management of ovarian cancer in young women depends heavily on the **stage of the disease** and the **desire for fertility preservation**. **Why Option A is Correct:** In a 25-year-old nulliparous woman (who likely desires future fertility), the primary goal for early-stage epithelial ovarian cancer is **Fertility-Sparing Surgery (FSS)**. Since the patient has already undergone a cystectomy and the diagnosis is serous cystadenocarcinoma, the standard approach for Stage IA (Grade 1 or 2) is unilateral salpingo-oophorectomy (USO). However, if the cyst was completely removed and staging is negative, close observation with **serial CA-125 levels and imaging** is the preferred follow-up strategy to monitor for recurrence while preserving the uterus and the contralateral ovary. **Why the other options are incorrect:** * **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 a 25-year-old nullipara, this would cause permanent infertility and surgical menopause, which is avoided unless the disease is advanced. * **Option C & D:** Epithelial ovarian cancers are generally **not radiosensitive**. Radiotherapy is not a primary or adjuvant treatment modality for serous cystadenocarcinoma; chemotherapy (carboplatin/paclitaxel) is the preferred adjuvant treatment if the stage is higher than IA. **Clinical Pearls for NEET-PG:** * **Fertility-Sparing Surgery (FSS):** Indicated in Stage IA, Grade 1 or 2 epithelial tumors. It involves USO and surgical staging, preserving the uterus and other ovary. * **Tumor Marker:** CA-125 is the most reliable marker for monitoring epithelial ovarian tumors, though it is less specific in premenopausal women due to conditions like endometriosis. * **Staging:** Ovarian cancer is staged **surgically** (FIGO staging). * **Most common type:** Serous cystadenocarcinoma is the most common malignant epithelial ovarian tumor.

Question 563: Which of the following statements regarding hydatidiform mole is correct?

A. 2% of cases may convert to carcinoma
B. It is diploid
C. There is an increase in beta-hCG levels
D. All of the above (Correct Answer)

Explanation: ### Explanation Hydatidiform mole (molar pregnancy) is a part of Gestational Trophoblastic Disease (GTD) characterized by abnormal proliferation of trophoblastic tissue and hydropic degeneration of chorionic villi. **Why "All of the above" is correct:** * **Conversion to Carcinoma:** Approximately **2% of complete hydatidiform moles** progress to choriocarcinoma (a highly malignant epithelial tumor). While the risk of developing persistent Gestational Trophoblastic Neoplasia (GTN) is higher (15–20%), the specific conversion rate to frank choriocarcinoma is historically cited around 2-3%. * **Diploid Nature:** A **Complete Mole** is typically **diploid (46,XX or 46,XY)**. It is androgenetic in origin, usually formed when a "blighted" ovum (no maternal nucleus) is fertilized by a single sperm that duplicates its chromosomes (90%) or by two sperm (10%). Note: Partial moles are triploid (69,XXX/XXY). * **Increased beta-hCG:** Trophoblastic hyperplasia leads to excessive production of human chorionic gonadotropin. In molar pregnancies, **beta-hCG levels are disproportionately high** for the period of gestation (often >100,000 mIU/mL), which is a key diagnostic marker. **High-Yield Clinical Pearls for NEET-PG:** 1. **Snowstorm Appearance:** The classic ultrasound finding due to multiple hydropic villi. 2. **Theca Lutein Cysts:** Occur in 25-30% of cases due to extreme ovarian stimulation by high hCG. 3. **Management:** Suction evacuation is the treatment of choice regardless of uterine size. 4. **Follow-up:** Weekly beta-hCG monitoring until three consecutive negative results, then monthly for 6 months to ensure no malignant transformation. 5. **Karyotype Distinction:** Complete Mole = 46,XX (Diploid); Partial Mole = 69,XXY (Triploid).

Question 564: Carcinoma of the cervix stage IA1 is defined by which of the following depth of invasion?

A. Less than 3 mm depth of stromal invasion (Correct Answer)
B. Less than 7 mm depth of stromal invasion
C. Greater than 3 mm depth of stromal invasion
D. Greater than 7 mm depth of stromal invasion

Explanation: **Explanation:** The staging of Cervical Cancer is based on the **FIGO (International Federation of Gynecology and Obstetrics) classification**. Stage I is defined as carcinoma strictly confined to the cervix. Stage IA represents **microscopically diagnosed** invasive carcinoma, where the lesion is not visible to the naked eye. * **Stage IA1:** Defined as measured stromal invasion **less than 3.0 mm** in depth. * **Stage IA2:** Defined as measured stromal invasion **between 3.0 mm and less than 5.0 mm** in depth. **Why the other options are incorrect:** * **Option B & D:** The "7 mm" horizontal spread criterion was removed in the **2018 FIGO update**. Previously, Stage IA required a lateral extent of <7 mm, but current staging relies solely on the **depth of invasion**. * **Option C:** Invasion greater than 3 mm (but less than 5 mm) would categorize the disease as **Stage IA2**. If the invasion exceeds 5 mm, it is classified as Stage IB. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Stage IA1 and IA2 are diagnosed via **microscopy** (usually through a cone biopsy or LEEP), not clinical examination. * **Management:** For Stage IA1 without lymphovascular space invasion (LVSI), **Extra-fascial Hysterectomy** (Type A) or even **Conization** (if fertility preservation is desired) is sufficient. * **Lymphovascular Space Invasion (LVSI):** The presence of LVSI does not change the FIGO stage but significantly influences the choice of surgical radicality. * **Stage IB1:** Now defined as invasion ≥ 5 mm depth and < 2 cm in greatest dimension.

Question 565: All of the following are known risk factors for the development of ovarian carcinoma except?

A. Family history of ovarian carcinoma
B. Use of oral contraceptives (Correct Answer)
C. Use of Clomiphene
D. BRCA-1 positive individual

Explanation: ### Explanation The development of epithelial ovarian carcinoma is closely linked to the **"Incessant Ovulation Theory."** This theory suggests that repeated trauma to the ovarian surface epithelium during ovulation, followed by inflammatory repair processes, increases the risk of malignant transformation. **Why "Use of Oral Contraceptives" is the correct answer:** Oral Contraceptive Pills (OCPs) are **protective** against ovarian cancer, not a risk factor. By suppressing ovulation, OCPs provide "rest" to the ovarian epithelium. Using OCPs for 5 years reduces the lifetime risk of ovarian cancer by approximately 50%. This protective effect persists for up to 15–20 years after discontinuation. **Analysis of Incorrect Options:** * **Family History:** A first-degree relative with ovarian cancer significantly increases risk. About 10–15% of cases have a hereditary component. * **Use of Clomiphene:** Clomiphene citrate is an ovulation-inducing agent. Prolonged use (usually >12 cycles), especially in women who do not achieve pregnancy, is associated with an increased risk due to "super-ovulation." * **BRCA-1 Positive:** This is the strongest genetic risk factor. BRCA-1 mutation carriers have a 40–50% lifetime risk of developing ovarian cancer (compared to 1.3% in the general population). **NEET-PG High-Yield Pearls:** * **Protective Factors:** OCPs, Pregnancy (Multiparity), Breastfeeding, and Tubal Ligation/Salpingectomy (prevents migration of precursors from the fallopian tube). * **Risk Factors:** Nulliparity, Early menarche, Late menopause, Endometriosis (linked to Clear cell and Endometrioid types), and Lynch Syndrome (HNPCC). * **Most Common Type:** Serous cystadenocarcinoma is the most common epithelial ovarian malignancy.

Question 566: A 55-year-old nulliparous black woman has a large, fungating tumor projecting from her cervix. A biopsy reveals a background of spindle-shaped cells with over 10 mitoses per high power field. Many of the mitoses have abnormal mitotic spindles. What is the most likely diagnosis?

A. Sarcomatous transformation of a uterine leiomyoma
B. Malignant mixed mullerian tumor
C. Well-differentiated endometrial carcinoma
D. Well-differentiated cervical carcinoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **Well-differentiated cervical carcinoma**. **1. Why the correct answer is right:** The clinical presentation of a **large, fungating cervical mass** in a postmenopausal woman is highly suggestive of cervical malignancy. Histologically, the presence of **spindle-shaped cells** with high mitotic activity (**>10 mitoses per HPF**) and **abnormal mitotic spindles** (tripolar or multipolar mitoses) are hallmark features of malignancy. While "well-differentiated" usually implies a closer resemblance to normal tissue, in the context of cervical squamous cell carcinoma (specifically the spindle cell variant), these aggressive mitotic features are characteristic of the neoplastic process. **2. Why the other options are wrong:** * **Sarcomatous transformation of a uterine leiomyoma (Leiomyosarcoma):** While these also show >10 mitoses/HPF and spindle cells, they typically present as an intramural or submucosal uterine mass rather than a fungating cervical tumor. * **Malignant Mixed Mullerian Tumor (MMMT/Carcinosarcoma):** These are biphasic tumors containing both malignant epithelial (carcinoma) and mesenchymal (sarcoma) components. The biopsy described only spindle cells, not the heterologous or epithelial elements typical of MMMT. * **Well-differentiated endometrial carcinoma:** This would typically present with abnormal uterine bleeding and glandular (acinar) patterns on biopsy, not a fungating cervical mass with spindle cell morphology. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mitotic Index:** In uterine/cervical smooth muscle tumors, >10 mitoses per 10 HPF is a primary criterion for diagnosing malignancy (Leiomyosarcoma). * **Risk Factors:** Nulliparity and postmenopausal status are significant risk factors for both endometrial and cervical cancers. * **Spindle Cell Variant:** Squamous cell carcinoma of the cervix can occasionally present with a sarcomatoid (spindle cell) appearance, which can mimic true sarcomas. * **Abnormal Mitoses:** The presence of "atypical" or "bizarre" mitoses is a specific indicator of malignancy over benign proliferative states.

Question 567: Which tumor marker is elevated in dysgerminoma?

A. Alpha-fetoprotein (AFP)
B. Lactate dehydrogenase (LDH) (Correct Answer)
C. Human chorionic gonadotropin (HCG)
D. Carbohydrate antigen 19-9 (CA-19-9)

Explanation: **Explanation:** **Dysgerminoma** is the most common malignant germ cell tumor of the ovary, typically occurring in young women and adolescents. It is the female counterpart of the testicular seminoma. **Why LDH is the correct answer:** Lactate dehydrogenase (LDH) is the classic, highly sensitive tumor marker for dysgerminoma. It reflects the high turnover rate of the undifferentiated germ cells. While not entirely specific, it is used for both initial diagnosis and monitoring treatment response/recurrence. Occasionally, dysgerminomas may also show mild elevations in **Alkaline Phosphatase (ALP)**. **Analysis of Incorrect Options:** * **A. Alpha-fetoprotein (AFP):** This is the characteristic marker for **Yolk Sac Tumors** (Endodermal Sinus Tumors). It is also elevated in immature teratomas and Sertoli-Leydig cell tumors. * **C. Human chorionic gonadotropin (HCG):** This is the primary marker for **Choriocarcinoma**. While 5% of dysgerminomas contain syncytiotrophoblastic giant cells that can produce low levels of HCG, it is not the primary diagnostic marker. * **D. CA-19-9:** This is a marker primarily associated with **pancreatic and biliary tract cancers**, as well as some mucinous ovarian tumors, but has no specific association with dysgerminoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common** malignant germ cell tumor in pregnancy: Dysgerminoma. * **Radiosensitivity:** Dysgerminomas are exquisitely radiosensitive (though surgery and chemotherapy are preferred to preserve fertility). * **Associated Condition:** Often associated with **gonadal dysgenesis** (Swyer Syndrome); if a dysgerminoma is found in a pre-menarcheal girl, a karyotype should be performed. * **Summary Table:** * Dysgerminoma → LDH * Yolk Sac Tumor → AFP (Schiller-Duval bodies) * Choriocarcinoma → hCG * Granulosa Cell Tumor → Inhibin B

Question 568: Suburethral metastasis is seen in which of the following?

A. Carcinoma cervix
B. Carcinoma endometrium (Correct Answer)
C. Choriocarcinoma
D. Vaginal carcinoma

Explanation: **Explanation:** The correct answer is **Carcinoma Endometrium**. **1. Why Carcinoma Endometrium is correct:** Suburethral metastasis (also known as a suburethral "drop" metastasis) is a classic, high-yield clinical finding associated with **Endometrial Carcinoma**. The spread occurs via the **retrograde lymphatic pathway**. Specifically, lymphatics from the body of the uterus communicate with the vaginal plexus. Malignant cells travel downward through these channels, often depositing in the anterior vaginal wall, specifically in the suburethral region. This is a sign of advanced disease (Stage III under the FIGO classification). **2. Why other options are incorrect:** * **Carcinoma Cervix:** Primarily spreads via direct extension to the parametrium or through pelvic lymph nodes (obturator, external iliac). While it can involve the vagina, it typically affects the upper third rather than forming a discrete suburethral nodule. * **Choriocarcinoma:** This is a highly vascular tumor that characteristically spreads via the **hematogenous route**. While it frequently metastasizes to the vagina, these lesions are typically described as "purplish, friable, vascular nodules" that bleed profusely, rather than the classic suburethral metastasis associated with endometrial cancer. * **Vaginal Carcinoma:** This refers to the primary tumor itself. While it can occur anywhere in the vagina, the term "metastasis" implies a secondary spread from a distant primary site, which is the hallmark of the endometrial-suburethral relationship. **Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis in Endometrial CA:** Lungs. * **Most common site of vaginal metastasis in Endometrial CA:** Lower third of the anterior vaginal wall (Suburethral). * **FIGO Staging:** Vaginal involvement in endometrial cancer automatically upgrades the disease to **Stage IIIB**. * **Triad of Endometrial CA:** Obesity, Diabetes, and Hypertension (Corpus Uteri Cancer Syndrome).

Question 569: Gestational trophoblastic neoplasia includes all except?

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

Explanation: **Explanation:** The core concept in this question lies in the distinction between **Gestational Trophoblastic Disease (GTD)** and **Gestational Trophoblastic Neoplasia (GTN)**. While GTD is an umbrella term encompassing all proliferative disorders of the placenta, GTN specifically refers to the subset that is **malignant** or has the potential for local invasion and metastasis. 1. **Why Option A is the Correct Answer:** A **Complete Hydatidiform Mole** is considered a benign form of GTD. Although it has a risk of progressing to malignancy (approx. 15-20%), the mole itself is not classified as a neoplasia until there is evidence of persistent elevation of hCG or clinical invasion. Therefore, it is excluded from the definition of GTN. 2. **Why Other Options are Incorrect:** * **Invasive Mole (Option B):** Characterized by the invasion of molar villi into the myometrium; it is the most common form of GTN following a hydatidiform mole. * **Choriocarcinoma (Option C):** A highly malignant, epithelial tumor that lacks chorionic villi and spreads hematogenously. It is a classic component of GTN. * **Placental Site Trophoblastic Tumor (PSTT) (Option D):** A rare GTN arising from intermediate trophoblasts at the placental site. It is unique because it produces low levels of hCG but high levels of Human Placental Lactogen (hPL). **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Staging:** Only GTN (Invasive mole, Choriocarcinoma, PSTT, and Epithelioid Trophoblastic Tumor) is staged using the FIGO anatomical staging and WHO scoring system. * **Karyotype:** Complete Mole is usually **46,XX** (diploid, paternal origin), whereas Partial Mole is **69,XXY** (triploid). * **Management:** The primary treatment for GTN is chemotherapy (Methotrexate or Actinomycin-D), whereas the primary treatment for a Hydatidiform Mole is **Suction and Evacuation**.

Question 570: What is the stage of vaginal carcinoma when there is involvement of the pelvis?

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

Explanation: **Explanation:** The staging of vaginal carcinoma follows the **FIGO (International Federation of Gynecology and Obstetrics)** classification system. The correct answer is **Stage III** because this stage specifically denotes the extension of the tumor beyond the primary site to involve the pelvic structures. * **Stage III (Correct):** This stage is defined by the carcinoma extending to the **pelvic wall** and/or involving the **lower third of the vagina**. It also includes cases with biopsy-proven metastatic **pelvic or inguinal lymph nodes**, regardless of the primary tumor size. * **Stage I (Incorrect):** The carcinoma is strictly limited to the **vaginal wall**. There is no extension into the surrounding tissues or lymph nodes. * **Stage II (Incorrect):** The carcinoma has involved the **paravaginal tissues** (subvaginal tissues) but has **not** reached the pelvic wall. * **Stage IV (Incorrect):** This represents advanced disease. **Stage IVA** involves the mucosa of the bladder or rectum, or extension beyond the true pelvis. **Stage IVB** involves distant metastasis (e.g., lungs, liver). **High-Yield Clinical Pearls for NEET-PG:** * **Primary vs. Secondary:** Primary vaginal cancer is rare. Most vaginal cancers are metastatic (secondary), most commonly from the cervix or endometrium. * **Histology:** The most common histological type is **Squamous Cell Carcinoma (SCC)**, often associated with high-risk HPV (16 and 18). * **Location:** The most common site for primary vaginal cancer is the **upper third of the posterior vaginal wall**. * **Lymphatic Drainage:** This is a frequent exam topic. The **upper 2/3** drains to the pelvic (iliac) nodes, while the **lower 1/3** drains to the inguinal and femoral nodes.

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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