Gynecologic Oncology — MCQs

A 55-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal examination reveal the parametrium is free of disease but the upper part of the vagina is involved with tumor. Intravenous pyelogram and sigmoidoscopy are negative, but a CT scan of the abdomen and pelvis shows grossly enlarged pelvic and para-aortic nodes. Thus, the patient is classified as Stage:

Q586Easy

Which of the following is an indication for colposcopy?

Q587Medium

A 23-year-old pregnant woman at 16 weeks gestation presents with vaginal spotting. Her uterus is enlarged to 28 weeks' size, and no fetal heart sounds are audible with a fetal Doppler. Her serum human chorionic gonadotropin (hCG) levels are 100,000 mIU/mL. Which of the following tests is most appropriate at this time?

Q588Easy

What is the characteristic feature of carcinoma of the fallopian tube?

Q589Easy

What is the primary treatment for early-stage vulvar carcinoma?

Q590Medium

In carcinoma of the cervix, lymphatic spread involves which of the following lymph nodes?

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 581: Which of the following is NOT true about serous cystadenoma of the ovary?

A. Bilateral
B. Unilateral
C. Concentric calcification
D. Multiloculated, sticky, gelatinous fluid (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (Multiloculated, sticky, gelatinous fluid)** because this description is characteristic of **Mucinous cystadenoma**, not Serous cystadenoma. 1. **Why Option D is the correct choice (The "False" statement):** Serous cystadenomas are typically filled with thin, straw-colored, watery (serous) fluid. In contrast, mucinous tumors are characterized by thick, viscid, gelatinous material (mucin) and are more frequently multiloculated with multiple small cysts. 2. **Why Options A and B are wrong:** Serous cystadenomas are the most common benign epithelial ovarian tumors. While they are often **unilateral** (approx. 80%), they have a higher propensity for **bilaterality** (approx. 20%) compared to mucinous tumors (only 5% bilateral). Therefore, both unilateral and bilateral presentations are clinically true. 3. **Why Option C is wrong:** Serous tumors (both benign and malignant) are associated with **Psammoma bodies**, which are microscopic, laminated, **concentric calcifications**. These are a classic histopathological hallmark of serous neoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common:** Serous cystadenoma is the most common benign epithelial tumor of the ovary. * **Psammoma Bodies:** Always associate these with Serous Ovarian Cancer, Papillary Thyroid Cancer, and Meningioma. * **Size:** Mucinous tumors are known for reaching massive sizes, often filling the entire abdominal cavity. * **Risk of Rupture:** Rupture of a mucinous tumor can lead to **Pseudomyxoma Peritonei** (jelly belly). * **Lining:** Serous tumors are lined by ciliated columnar epithelium (resembling the fallopian tube), while mucinous tumors are lined by endocervical-like cells.

Question 582: What is the commonest presenting symptom of cervical carcinoma?

A. Bleeding per vaginum (Correct Answer)
B. Pain
C. White discharge per vaginum
D. Dyspareunia

Explanation: **Explanation:** **Cervical carcinoma** is the most common gynecological malignancy in India. The correct answer is **Bleeding per vaginum** because the hallmark of cervical cancer is a friable, vascular tumor mass. As the neoplastic growth invades the cervical stroma and surface epithelium, the delicate new blood vessels (neovascularization) rupture easily upon contact or spontaneously. * **Post-coital bleeding** is the most specific early clinical sign. * **Intermenstrual bleeding** or **post-menopausal bleeding** are also frequent presentations. **Analysis of Incorrect Options:** * **B. Pain:** This is typically a **late feature**. Pain indicates advanced disease (Stage IIIB or IV), suggesting involvement of the pelvic side walls, nerve plexus compression, or hydronephrosis due to ureteric obstruction. * **C. White discharge per vaginum:** While a foul-smelling, serosanguinous (watery) discharge can occur due to secondary infection or tumor necrosis, it is usually secondary to the primary symptom of bleeding. * **D. Dyspareunia:** This may occur due to local tumor bulk or vaginal involvement, but it is far less common as an initial presenting complaint compared to bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (80-90%). * **Most common cause of death:** Uremia (due to bilateral ureteric obstruction leading to post-renal failure). * **Screening:** PAP smear is the gold standard for screening; however, **Visual Inspection with Acetic Acid (VIA)** is the preferred community-based screening method in low-resource settings. * **Staging:** Cervical cancer is now staged **clinically and radiologically** (FIGO 2018).

Question 583: Lynch syndrome is associated with cancers of:

A. Breast, colon, ovary
B. Breast, endometrium, ovary
C. Breast, colon, endometrium
D. Colon, endometrium, ovary (Correct Answer)

Explanation: **Explanation:** Lynch syndrome, also known as **Hereditary Non-Polyposis Colorectal Cancer (HNPCC)**, is an autosomal dominant condition caused by germline mutations in **DNA mismatch repair (MMR) genes** (*MLH1, MSH2, MSH6, PMS2*). This leads to microsatellite instability and a significantly increased lifetime risk of multiple malignancies. **Why Option D is Correct:** The "classic triad" of cancers associated with Lynch syndrome includes: 1. **Colon Cancer:** The most common, with a lifetime risk of up to 80%. 2. **Endometrial Cancer:** The most common extracolonic manifestation. In women, the risk of endometrial cancer (40–60%) often equals or exceeds the risk of colon cancer, frequently serving as the sentinel (first) cancer. 3. **Ovarian Cancer:** Increased risk (approx. 10–12%), typically presenting as endometrioid or clear cell subtypes. **Why Other Options are Incorrect:** * **Options A, B, and C:** These all include **Breast Cancer**. While some studies suggest a marginal increase in breast cancer risk, it is **not** considered a core component of Lynch syndrome. Breast cancer is primarily associated with **BRCA1/BRCA2** mutations (Hereditary Breast and Ovarian Cancer syndrome). **High-Yield Clinical Pearls for NEET-PG:** * **Amsterdam II Criteria:** Used for clinical diagnosis (3-2-1 rule: 3 relatives, 2 generations, 1 diagnosed before age 50). * **Screening:** Annual transvaginal ultrasound and endometrial biopsy are recommended starting at age 30–35. * **Prophylaxis:** Risk-reducing Total Laparoscopic Hysterectomy with Bilateral Salpingo-oophorectomy (TLH with BSO) is recommended after completion of childbearing (usually age 40). * **Other associated cancers:** Gastric, small bowel, ureter, and renal pelvis.

Question 584: Prophylactic chemotherapy in hydatidiform mole should preferably be given:

A. Prior to evacuation as a routine
B. Following evacuation as a routine
C. In selected cases following evacuation (Correct Answer)
D. As a routine 6 weeks postevacuation

Explanation: **Explanation:** The primary management for a hydatidiform mole is **suction evacuation** followed by serial monitoring of serum β-hCG levels. Prophylactic chemotherapy is **not recommended as a routine practice** because it can mask the development of persistent gestational trophoblastic neoplasia (GTN), increase the risk of drug resistance, and expose patients to unnecessary toxicity. **Why Option C is correct:** Prophylactic chemotherapy (usually with Methotrexate or Actinomycin D) is reserved for **selected high-risk cases** where the risk of malignant transformation is high and the patient is likely to be lost to follow-up. High-risk criteria include: * Pre-evacuation β-hCG >100,000 mIU/mL. * Excessive uterine enlargement for gestational age. * Theca lutein cysts >6 cm. * Age >40 years. **Analysis of Incorrect Options:** * **Options A, B, and D:** Routine use (whether before, immediately after, or 6 weeks post-evacuation) is contraindicated. In 80–90% of cases, evacuation alone is curative. Routine administration leads to over-treatment and potential development of chemo-resistant trophoblastic cells. **Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** Suction evacuation is the treatment of choice regardless of uterine size. * **Follow-up:** Weekly β-hCG until three consecutive normal values are obtained, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (COCPs) are preferred during the follow-up period to prevent pregnancy (which would confuse hCG monitoring). * **Risk of Malignancy:** Approximately 15–20% for complete moles and <5% for partial moles.

Question 585: A 55-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal examination reveal the parametrium is free of disease but the upper part of the vagina is involved with tumor. Intravenous pyelogram and sigmoidoscopy are negative, but a CT scan of the abdomen and pelvis shows grossly enlarged pelvic and para-aortic nodes. Thus, the patient is classified as Stage:

A. IIa (Correct Answer)
B. IIb
C. IIIa
D. IIIb

Explanation: ### Explanation The staging of cervical cancer is primarily based on the **FIGO Staging System**. In this case, the patient is classified as **Stage IIa** based on the clinical findings of vaginal involvement without parametrial extension. **1. Why Stage IIa is Correct:** According to FIGO staging, **Stage II** involves the tumor extending beyond the uterus but not to the pelvic wall or the lower third of the vagina. * **Stage IIa:** Involvement of the upper two-thirds of the vagina without parametrial involvement. * **Stage IIb:** Involvement of the parametrium. Since the pelvic/rectal exam confirms the parametrium is free but the upper vagina is involved, it fits the criteria for IIa. **2. Why the other options are incorrect:** * **Stage IIb:** Incorrect because the clinical exam specifically stated the parametrium is free of disease. * **Stage IIIa:** Incorrect because this stage requires involvement of the **lower third** of the vagina. * **Stage IIIb:** Incorrect because this involves extension to the pelvic wall and/or causes hydronephrosis/non-functioning kidney (IVP was negative here). **3. The "CT Scan" Trap (High-Yield Concept):** A crucial point for NEET-PG is that FIGO staging for cervical cancer was traditionally **clinical**. While the 2018 FIGO update allows imaging (CT/MRI) to assign a stage (Stage IIIC for nodal involvement), many exam questions still test the classic clinical staging rules or specific anatomical extensions. In the context of this classic question, **lymph node status on CT does not change the T-stage (local extension)** unless specifically asked for the 2018 IIIC revision. **Clinical Pearls for NEET-PG:** * **Stage IIa1:** Lesion ≤ 4 cm. * **Stage IIa2:** Lesion > 4 cm. * **Most common site of spread:** Direct extension (lateral into parametrium). * **Investigation of choice for staging (2018):** MRI is preferred for local tumor extent; PET-CT for nodal/distant spread.

Question 586: Which of the following is an indication for colposcopy?

A. Suspicious Pap smear (Correct Answer)
B. Obvious mass seen
C. Suspected invasive carcinoma
D. Patient who refuses biopsy

Explanation: **Explanation:** The primary purpose of **colposcopy** is to evaluate the cervix under magnification to identify the most suspicious areas for a directed biopsy. It acts as a bridge between a screening test (Pap smear) and a definitive histological diagnosis. **1. Why Option A is correct:** A **Suspicious Pap smear** (e.g., LSIL, HSIL, or persistent ASC-US) is the classic indication for colposcopy. Since a Pap smear is a cytological screening tool, it cannot pinpoint the exact location or severity of a lesion. Colposcopy allows the clinician to visualize the transformation zone, apply acetic acid to identify "acetowhite" areas, and perform a **directed biopsy** to confirm the grade of Cervical Intraepithelial Neoplasia (CIN). **2. Why the other options are incorrect:** * **Options B & C (Obvious mass/Suspected invasive carcinoma):** If a growth or mass is visible to the naked eye, colposcopy is unnecessary and may delay diagnosis. These cases require a **direct punch biopsy** of the lesion immediately. Colposcopy is intended for "occult" or microscopic lesions not visible to the naked eye. * **Option D (Patient refuses biopsy):** Colposcopy is a diagnostic procedure often followed by a biopsy. If a patient refuses a biopsy, the clinical utility of colposcopy is significantly diminished, as a definitive diagnosis cannot be reached. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Colposcopy:** Abnormal Pap smear, positive High-risk HPV DNA test, post-coital bleeding with a normal-looking cervix, or suspicious findings on visual inspection with acetic acid (VIA). * **The "Gold Standard"** for diagnosing cervical cancer is a **histopathological biopsy**, not colposcopy or Pap smear. * **Reid’s Colposcopic Index:** Used to grade the severity of lesions based on color, margins, vessels, and iodine staining. * **Contraindications:** There are no absolute contraindications, but it is usually deferred during active heavy menses or acute pelvic inflammatory disease (PID).

Question 587: A 23-year-old pregnant woman at 16 weeks gestation presents with vaginal spotting. Her uterus is enlarged to 28 weeks' size, and no fetal heart sounds are audible with a fetal Doppler. Her serum human chorionic gonadotropin (hCG) levels are 100,000 mIU/mL. Which of the following tests is most appropriate at this time?

A. Serial clotting function studies
B. Pelvic ultrasound (Correct Answer)
C. Serial hCG estimation
D. Apt test on vaginal blood

Explanation: **Explanation:** The clinical presentation of a **size-greater-than-dates** uterus (28 weeks size at 16 weeks gestation), vaginal spotting, and absent fetal heart sounds is highly suggestive of a **Gestational Trophoblastic Disease (GTD)**, specifically a Hydatidiform Mole. **1. Why Pelvic Ultrasound is the Correct Answer:** Pelvic ultrasound is the **gold standard investigation** for diagnosing a molar pregnancy. It will typically reveal a characteristic **"snowstorm appearance"** (multiple echogenic areas representing hydropic villi) and the absence of a fetus in a complete mole. It is the most appropriate next step to confirm the diagnosis before proceeding to management (suction evacuation). **2. Analysis of Incorrect Options:** * **Serial clotting function studies (A):** While disseminated intravascular coagulation (DIC) can occur in molar pregnancies, it is not the primary diagnostic tool. These are done pre-operatively, not as the initial diagnostic test. * **Serial hCG estimation (C):** A single high hCG value is suggestive, but not diagnostic, as high levels can also be seen in multiple pregnancies. Serial hCG is crucial for **post-evacuation follow-up** to monitor for malignant transformation (Gestational Trophoblastic Neoplasia), but not for the initial diagnosis. * **Apt test (D):** This test is used to differentiate fetal blood from maternal blood (e.g., in suspected vasa previa). It has no role in diagnosing GTD. **Clinical Pearls for NEET-PG:** * **Most common symptom of Molar Pregnancy:** Vaginal bleeding. * **Most common sign:** Size > Dates (seen in ~50% of cases). * **Theca Lutein Cysts:** Often seen bilaterally on ultrasound due to very high hCG levels. * **Treatment of choice:** Suction and Evacuation (regardless of uterine size). * **HCG levels:** Usually >100,000 mIU/mL, but the definitive diagnosis is always radiological (USG) and confirmed by histopathology.

Question 588: What is the characteristic feature of carcinoma of the fallopian tube?

A. Watery discharge per vaginam (Correct Answer)
B. Hemorrhage
C. Pain
D. Sepsis

Explanation: **Explanation:** Primary carcinoma of the fallopian tube is a rare gynecological malignancy, often presenting with the classic clinical triad known as **Latzko’s Triad**: intermittent profuse watery vaginal discharge, pelvic pain, and a palpable pelvic mass. **Why Option A is Correct:** The characteristic feature is **Hydrops Tubae Profluens**. This occurs when the fimbrial end of the fallopian tube is occluded, causing secretions (serous fluid) from the tumor to accumulate and distend the tube. When the pressure overcomes the resistance of the uterine end, the fluid suddenly escapes through the uterus and out of the vagina. This results in a sudden gush of watery discharge, often followed by the disappearance of a previously palpable pelvic mass and relief of colicky pain. **Why Other Options are Incorrect:** * **B. Hemorrhage:** While postmenopausal bleeding can occur, it is less specific than the pathognomonic watery discharge. * **C. Pain:** Pain is a common symptom (colicky due to tubal peristalsis), but it is not as characteristic or diagnostic as the specific nature of the discharge. * **D. Sepsis:** Sepsis is a late-stage complication of any pelvic malignancy or secondary infection, not a primary diagnostic feature. **High-Yield Clinical Pearls for NEET-PG:** * **Latzko’s Triad:** (1) Intermittent profuse watery vaginal discharge, (2) Colicky pelvic pain, (3) Pelvic mass. * **Most common histology:** Serous adenocarcinoma (similar to ovarian cancer). * **Diagnosis:** Often made incidentally during surgery for a presumed adnexal mass. Pre-operative diagnosis is rare. * **Staging:** Follows the **FIGO staging** system, similar to ovarian cancer.

Question 589: What is the primary treatment for early-stage vulvar carcinoma?

A. Radiotherapy
B. Chemotherapy
C. Surgery (Correct Answer)
D. Chemoradiation

Explanation: **Explanation:** **Surgery** is the primary treatment for early-stage vulvar carcinoma (Stage I and II). The goal is to achieve a wide local excision with at least 1 cm of tumor-free margins. For lesions with a depth of invasion >1 mm, surgical evaluation of the groin nodes (via Sentinel Lymph Node Biopsy or Inguinal-femoral Lymphadenectomy) is mandatory, as nodal status is the most important prognostic factor. **Why other options are incorrect:** * **Radiotherapy (A):** While vulvar cancer is radiosensitive, radiation is typically reserved as adjuvant therapy for positive margins, multiple positive nodes, or extracapsular spread. It may be used as primary therapy only in advanced cases where surgery is disfiguring. * **Chemotherapy (B):** Systemic chemotherapy alone is not curative for vulvar cancer. It is primarily used as a radiosensitizer or for palliative management in metastatic disease. * **Chemoradiation (D):** This is the standard of care for **locally advanced** disease (Stage III/IV) to shrink the tumor before surgery or as definitive treatment when the tumor involves the anus, urethra, or bladder. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (90%). * **Staging:** Vulvar cancer is staged **surgically** (FIGO). * **Lymphatic Spread:** Follows a predictable pattern: Superficial inguinal → Deep inguinal → Cloquet’s node → External iliac nodes. * **Sentinel Lymph Node Biopsy (SLNB):** Indicated for unifocal lesions <4 cm with clinically negative nodes.

Question 590: In carcinoma of the cervix, lymphatic spread involves which of the following lymph nodes?

A. Obturator, External Iliac, and Inguinal lymph nodes
B. External Iliac, Inguinal, and Femoral lymph nodes
C. Obturator, External Iliac, and Hypogastric lymph nodes (Correct Answer)
D. Obturator, Inguinal, and Femoral lymph nodes

Explanation: **Explanation:** The lymphatic drainage of the cervix follows a predictable, stepwise pattern primarily involving the pelvic lymph nodes. The cervix drains into the **primary group** of nodes, which are the first line of spread in cervical cancer. **1. Why Option C is Correct:** The lymphatic spread of carcinoma cervix occurs via three main channels: * **Lateral:** To the **Obturator** and **External Iliac** nodes. * **Posterolateral:** To the **Hypogastric (Internal Iliac)** nodes. * **Posterior:** To the Presacral nodes. The Obturator node is clinically significant as it is often the first node involved (the "Leveuf and Godard" node). Together, the Obturator, External Iliac, and Hypogastric nodes constitute the primary nodal drainage for the cervix. **2. Why Other Options are Incorrect:** * **Options A, B, and D:** These options include **Inguinal** and **Femoral** lymph nodes. These nodes drain the vulva, the lower third of the vagina, and the skin of the perineum. They are *not* part of the primary drainage of the cervix. Inguinal involvement in cervical cancer only occurs in very advanced stages if the disease spreads to the lower third of the vagina. **3. NEET-PG High-Yield Pearls:** * **Primary Nodes:** Obturator (most common), External Iliac, Internal Iliac (Hypogastric), and Paracervical nodes. * **Secondary Nodes:** Common Iliac, Para-aortic (indicates advanced disease/Stage IVB), and Presacral nodes. * **Sentinel Node:** The most common site for a sentinel lymph node biopsy in early CA Cervix is the **medial aspect of the External Iliac** or the **Obturator** space. * **Staging:** Lymph node involvement (pelvic or para-aortic) now upgrades the FIGO 2018 stage to **IIIC**.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

Gestational Trophoblastic Disease

Practice Questions

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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