Gynecologic Oncology Practice Questions

Q: An obese woman of 49 years of age, with a history of diabetes and hypertension, complains of heavy menstrual bleeding with delayed and irregular cycles. Which of the following is the most important cause that should be ruled out in this patient?

Endometrial cancer. ***Endometrial cancer*** - This patient has multiple risk factors for **endometrial cancer**, including **obesity**, **diabetes**, **hypertension**, and being in the **perimenopausal** age group (49 years old). - Her symptoms of heavy menstrual bleeding with delayed and irregular cycles are classic presentations of **endometrial hyperplasia** or **endometrial cancer**, warranting prompt investigation. *Cancer cervix* - While cervical cancer is a concern, its typical presentation often involves **post-coital bleeding** or **intermenstrual bleeding**, rather than heavy and irregular cycles, making other causes more likely in this specific scenario. - Risk factors for cervical cancer include **HPV infection**, early age of first intercourse, multiple sexual partners, and smoking, which are not mentioned here. *Fibroid uterus* - **Fibroids** can cause heavy menstrual bleeding, but the delayed and irregular cycles, combined with the patient's strong metabolic risk factors, make endometrial pathology a more urgent concern. - Fibroids are **benign tumors** and do not carry the same immediate malignancy risk as the presenting symptoms suggest for this patient profile. *Polycystic ovaries* - **PCOS** often presents with irregular or absent menstruation and infertility, usually in younger women, and is associated with obesity and insulin resistance. - While PCOS can lead to chronic anovulation and increased risk of **endometrial hyperplasia**, a 49-year-old with acute changes in bleeding pattern and metabolic syndrome points more directly to the need to rule out established endometrial malignancy.

Q: Prognosis of Gestational Trophoblastic Disease depends on all, except:

Number of living children. ***Number of living children*** - The number of living children is **not included** in the prognostic scoring systems for Gestational Trophoblastic Disease (GTD), such as the **FIGO scoring system**. - This is a personal/social factor unrelated to disease characteristics or tumor burden. - Therefore, it does **not** affect the prognosis of GTD. *Age* - **Age ≥40 years** is assigned 1 point in the FIGO prognostic scoring system. - Advanced maternal age is associated with **worse prognosis** in GTD. - This is a well-established prognostic factor. *Previous HCG titre* - The **pre-treatment serum hCG level** is a critical prognostic factor in the FIGO scoring system. - hCG levels are scored: 10⁵ (4 points). - Higher initial hCG levels indicate greater **tumor burden** and correlate with worse prognosis. *Site of metastases* - The **anatomic location of metastases** is a key prognostic factor in FIGO scoring. - Lung/vaginal metastases score lower (1-2 points) while spleen/kidney and GI/liver/brain metastases score higher (2-4 points). - Brain and liver metastases confer the **worst prognosis**.

Q: Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in serous ovarian carcinoma?

33%. ***Correct: 33%*** - Up to **one-third of patients** with serous ovarian carcinoma involving one ovary will have **microscopic involvement** of the contralateral, grossly normal ovary. - This high rate of occult involvement often necessitates **bilateral oophorectomy** in surgical staging for serous ovarian carcinoma. *Incorrect: 5%* - This percentage significantly **underestimates the true incidence** of contralateral involvement in serous ovarian carcinoma. - Serous carcinoma is known for its tendency to be **multifocal** and spread early, even when the presenting lesion appears unilateral. *Incorrect: 15%* - While higher than 5%, 15% still **underestimates the frequent bilateral nature** of serous ovarian carcinoma, even when one ovary appears normal. - Studies consistently show **higher rates of occult contralateral disease**, particularly for serous histologic types. *Incorrect: 45%* - This percentage is **somewhat higher than the generally accepted rate** for contralateral microscopic involvement in grossly normal ovaries affected by serous carcinoma. - While bilateral involvement is common, a 45% rate might be more reflective of **macroscopic or readily apparent involvement** rather than purely occult disease.

Q: Most common type of cervical cancer is:

Squamous cell carcinoma. ***Squamous cell carcinoma*** - This is by far the **most common type of cervical cancer**, accounting for approximately 70-80% of all cases. - It arises from the **squamous cells** on the exocervix, the outer part of the cervix that projects into the vagina. *Small cell carcinoma* - This is a **rare and highly aggressive** type of cervical cancer, accounting for less than 1% of cases. - It is associated with a **poor prognosis** and often requires intensive treatment. *Adenocarcinoma* - This type of cervical cancer accounts for about 10-20% of cases, making it the **second most common** type after squamous cell carcinoma. - It originates from the **glandular cells** of the endocervix, the inner part of the cervix. *Adenosquamous carcinoma* - This is a **rare mixed tumor** containing both squamous and glandular components, accounting for approximately 3-5% of cervical cancers. - It tends to have a **more aggressive behavior** and worse prognosis compared to pure adenocarcinoma or squamous cell carcinoma.

Q: At which anatomical site does cervical carcinoma most commonly develop?

Squamo-columnar junction (transformation zone). ***Squamo-columnar junction (transformation zone)*** - The **squamo-columnar junction**, also known as the **transformation zone**, is the site where the columnar epithelium of the endocervix meets the squamous epithelium of the ectocervix. - This area is highly susceptible to oncogenic changes due to its active metaplasia and exposure to risk factors like **human papillomavirus (HPV)**. *Isthmus* - The **isthmus** is the narrow lower portion of the uterus, between the cervix and the body of the uterus. - While it is part of the uterine structure, it is not the primary site for the development of cervical carcinoma. *Cervical lip* - The term **cervical lip** usually refers to the borders of the external os or the everted portion of the cervix. - While it's part of the cervix, it's not specifically identified as the most common origin point for carcinoma compared to the active cellular changes occurring at the squamo-columnar junction. *Internal os* - The **internal os** is the opening between the endocervical canal and the uterine cavity. - While it's a critical anatomical landmark, it does not represent the most common area for the initial development of cervical cancer.

Q: Carcinosarcoma most commonly arises in which organ?

Uterus. ***Uterus*** - Carcinosarcoma, also known as **malignant mixed Müllerian tumor**, commonly arises in the uterus, characterized by both **carcinomatous and sarcomatous components** [1]. - It typically presents with **postmenopausal bleeding** and is often diagnosed in older women [1]. *Ovary* - While ovarian tumors can be malignant, **carcinosarcoma is not commonly found** in the ovary; ovarian tumors are more often serous or mucinous in nature. - Ovarian cancer tends to present with **nonspecific abdominal symptoms** rather than the classic features of carcinosarcoma. *Vagina* - Vaginal cancers are rare, and while **sarcoma may occur here**, carcinosarcoma predominantly involves the uterus rather than the vagina. - The types of vaginal malignancies tend to be more commonly **squamous cell carcinomas** or adenocarcinomas. *Cervix* - Cervical cancers are predominantly **squamous cell carcinomas** or adenocarcinomas, and carcinosarcoma is not typically associated with the cervix. - The cervix also has distinctive associated risk factors, such as **HPV infection**, which are not linked to carcinosarcoma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1022-1024.

Q: Which tumor type is associated with an increased risk of endometrial carcinoma?

Granulosa theca cell. ***Granulosa theca cell*** - Granulosa-theca cell tumors are associated with an increased risk of **endometrial carcinoma** due to their potential to cause **excess estrogen production**. - The **estrogen stimulation** of the endometrium can lead to hyperplasia and subsequently to carcinoma. *Immature teratoma* - Immature teratomas are primarily germ cell tumors and are not typically associated with **endometrial cancer risk**. - Their malignant potential is primarily linked to **germ cell neoplasia** rather than estrogen exposure. *Sertoli Leydig cell* - Sertoli-Leydig cell tumors cause **androgen production** [1], which may have effects on the endometrium but do not significantly raise endometrial carcinoma risk. - These tumors are more associated with **virilization** [1] rather than estrogen-related pathways. *Gonadoblastoma tumor* - Gonadoblastomas are rare and typically found in individuals with **disorders of sexual development**; they are not commonly linked to endometrial cancer. - Their risk is more associated with **germ cell tumor presentation**, without significant impact on endometrial tissue. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1037-1038.

Q: Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?

CA-125 for ovarian cancer. ***CA-125 for ovarian cancer*** - **CA-125 lacks sufficient sensitivity and specificity** for screening asymptomatic women, leading to high rates of **false positives** and **false negatives**. - Major randomized trials (**UKCTOCS, PLCO**) demonstrated **no mortality benefit** from CA-125 screening and increased unnecessary invasive procedures. *USG in endometrial cancer* - **Transvaginal ultrasonography** effectively measures **endometrial thickness** and aids in risk stratification for symptomatic women. - While not used for population screening, it serves as a valuable **diagnostic adjunct** in evaluating postmenopausal bleeding and guiding biopsy decisions. *Pap smear for cervical cancer* - The **Pap smear** is the **gold standard** screening method that has dramatically reduced cervical cancer incidence and mortality. - It effectively detects **precancerous lesions** (CIN) and early cervical cancers, allowing for timely intervention and treatment. *Mammography for breast cancer* - **Mammography screening** is proven effective in reducing **breast cancer mortality** by 20-40% in women aged 50-69 years. - It can detect **early-stage breast cancers** and **microcalcifications** before they become palpable, enabling early treatment.

Question 1

Which of the following statements about carcinoma of the vulva is correct?

Accepted Answer

Commonly seen after menopause and associated with viral predisposition.

Answer

Spreads to iliac nodes.

Answer

Spreads to superficial inguinal nodes and is treated with radiotherapy.

Answer

All of the options.

Question 2

An obese woman of 49 years of age, with a history of diabetes and hypertension, complains of heavy menstrual bleeding with delayed and irregular cycles. Which of the following is the most important cause that should be ruled out in this patient?

Accepted Answer

Endometrial cancer

Answer

Cancer cervix

Answer

Fibroid uterus

Answer

Polycystic ovaries

Question 3

Prognosis of Gestational Trophoblastic Disease depends on all, except:

Accepted Answer

Number of living children

Answer

Age

Answer

Previous HCG titre

Answer

Site of metastases

Question 4

Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in serous ovarian carcinoma?

Accepted Answer

33%

Answer

5%

Answer

15%

Answer

45%

Question 5

Most common type of cervical cancer is:

Accepted Answer

Squamous cell carcinoma

Answer

Small cell carcinoma

Answer

Adenocarcinoma

Answer

Adenosquamous carcinoma

Question 6

At which anatomical site does cervical carcinoma most commonly develop?

Accepted Answer

Squamo-columnar junction (transformation zone)

Answer

Cervical lip

Answer

Isthmus

Answer

Internal os

Question 7

Carcinosarcoma most commonly arises in which organ?

Accepted Answer

Uterus

Answer

Cervix

Answer

Vagina

Answer

Ovary

Question 8

Which tumor type is associated with an increased risk of endometrial carcinoma?

Accepted Answer

Granulosa theca cell

Answer

Sertoli Leydig cell

Answer

Immature teratoma

Answer

Gonadoblastoma tumor

Question 9

In which of the following conditions is serial monitoring of β-HCG post-treatment most useful?

Accepted Answer

Hydatidiform mole

Answer

Choriocarcinoma

Answer

Ectopic pregnancy

Answer

None of the options

Question 10

Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?

Accepted Answer

CA-125 for ovarian cancer

Answer

USG in endometrial cancer

Answer

Pap smear for cervical cancer

Answer

Mammography for breast cancer

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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