Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 601: Carcinoma cervix with involvement of the upper two-thirds of the vagina is classified as which stage?

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

Explanation: This question tests your knowledge of the **FIGO Staging for Carcinoma Cervix** (revised 2018). ### **Explanation of the Correct Answer** **Stage II** is defined as carcinoma that extends beyond the uterus but has not reached the pelvic wall or the lower third of the vagina. It is subdivided based on the direction of spread: * **Stage IIA:** Involvement of the **upper two-thirds of the vagina** without parametrial involvement. * **IIA1:** Clinically visible lesion ≤ 4.0 cm in greatest dimension. * **IIA2:** Clinically visible lesion > 4.0 cm in greatest dimension. Since the question specifies involvement of the upper two-thirds of the vagina, **Stage IIA** is the correct classification. ### **Why Other Options are Incorrect** * **Stage IIB:** This involves spread to the **parametrium** but not reaching the pelvic side wall. * **Stage IIIA:** This involves the **lower third of the vagina** (without extension to the pelvic wall). * **Stage IIIB:** This involves extension to the **pelvic wall** and/or causes hydronephrosis or a non-functioning kidney. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Staging Method:** FIGO staging for cervical cancer is primarily **clinical**, but the 2018 revision now allows the use of **imaging (MRI/CT/PET)** and **pathological findings** to assign the stage. 2. **The "Lower Third" Rule:** If the cancer touches the lower third of the vagina, it automatically jumps to **Stage III**. 3. **Management Cut-off:** Generally, Stage I to IIA1 are treated surgically (e.g., Radical Hysterectomy), whereas **Stage IIA2 to IVA** are treated with **Concurrent Chemoradiotherapy (CCRT)**. 4. **Most Common Spread:** The most common mode of spread for Ca Cervix is **direct local extension**.

Question 602: The worst prognosis in patients with endometrial carcinoma is found in patients with tumour involvement of which of the following structures?

A. Uterine cervix
B. Upper vagina
C. Bladder mucosa (Correct Answer)
D. Parametrium

Explanation: **Explanation:** The prognosis of endometrial carcinoma is primarily determined by the **FIGO Staging system**. The involvement of the bladder mucosa represents **Stage IVA** disease, indicating direct extension of the tumor beyond the true pelvis to adjacent organs. **Why Bladder Mucosa is the Correct Answer:** According to the FIGO staging for endometrial cancer: * **Stage I:** Confined to the corpus uteri. * **Stage II:** Invades cervical stroma. * **Stage III:** Local/regional spread (Vagina, Parametrium, Lymph nodes). * **Stage IV:** Distant metastasis or involvement of the **bladder/bowel mucosa**. Involvement of the bladder mucosa (Stage IVA) signifies advanced, extragenital spread, which carries a significantly higher risk of mortality and a lower 5-year survival rate compared to tumors confined to the pelvic reproductive organs. **Analysis of Incorrect Options:** * **Uterine Cervix (Stage II):** This indicates cervical stromal invasion. While it carries a worse prognosis than Stage I, it is still considered "locoregional" and is surgically resectable. * **Upper Vagina (Stage IIIB):** This represents vaginal or parametrial involvement. While advanced, it is still staged lower than Stage IV. * **Parametrium (Stage IIIB):** Similar to vaginal involvement, this indicates spread within the true pelvis but does not carry the grave prognosis associated with mucosal organ invasion or distant metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Endometrioid adenocarcinoma (Type I). * **Most common site of distant metastasis:** Lungs. * **Staging Method:** Endometrial cancer is **surgically staged** (unlike Cervical cancer, which is clinically staged). * **Prognostic Hierarchy:** Stage IV (Bladder/Bowel) > Stage III (Adnexa/Vagina/Nodes) > Stage II (Cervix) > Stage I (Uterus).

Question 603: Which of the following is NOT a predisposing factor for carcinoma of the vulva?

A. Smoking
B. Human Papillomavirus (HPV) infection
C. Fibroepithelial polyp (Correct Answer)
D. Leukoplakia

Explanation: **Explanation:** Carcinoma of the vulva primarily follows two distinct etiopathogenic pathways. Understanding these pathways is key to identifying predisposing factors. **Why Fibroepithelial Polyp is the correct answer:** A **fibroepithelial polyp** (commonly known as a skin tag or acrochordon) is a benign, non-neoplastic mesenchymal lesion. It consists of a vascularized connective tissue core covered by squamous epithelium. It has **no malignant potential** and is not associated with the development of vulvar intraepithelial neoplasia (VIN) or invasive carcinoma. **Analysis of Incorrect Options:** * **Smoking:** Smoking is a significant co-factor, especially in the HPV-related pathway. It induces local immunosuppression and concentrates carcinogens in the lower genital tract, increasing the risk of VIN and its progression to cancer. * **Human Papillomavirus (HPV):** HPV types 16, 18, and 33 are strongly associated with the "Basaloid/Warty" type of vulvar cancer, typically seen in younger women. * **Leukoplakia:** This is a clinical term for a white patch. In the context of the vulva, it often represents **Lichen Sclerosus** or Squamous Cell Hyperplasia. Lichen sclerosus is the most common precursor for the "Differentiated" (HPV-negative) type of vulvar cancer, usually seen in elderly women. **NEET-PG High-Yield Pearls:** 1. **Most common histological type:** Squamous Cell Carcinoma (90%). 2. **Precursor lesions:** VIN (associated with HPV) and Lichen Sclerosus (associated with dVIN/HPV-negative). 3. **Lymphatic Spread:** Vulvar cancer spreads primarily via lymphatics to the **inguinal nodes** (sentinel nodes). The "Cloquet’s node" is the highest deep inguinal node. 4. **Staging:** Vulvar cancer is staged surgically (FIGO).

Question 604: What is the recommended treatment for stage IB2 carcinoma of the cervix?

A. Concurrent chemoradiation (Correct Answer)
B. Surgery
C. Neoadjuvant chemotherapy followed by radiotherapy
D. Radiotherapy alone

Explanation: **Explanation:** The management of cervical cancer is primarily determined by the **FIGO staging**. According to the revised FIGO 2018 classification, **Stage IB2** refers to a tumor limited to the cervix with a maximum diameter of **≥2 cm and <4 cm**. **Why Option A is correct:** For "bulky" early-stage disease (historically defined as >4 cm, but increasingly applied to tumors ≥2 cm in modern guidelines), **Concurrent Chemoradiation (CCRT)** is the treatment of choice. Clinical trials (GOG) have demonstrated that adding cisplatin-based chemotherapy to radiotherapy significantly improves overall survival and reduces recurrence compared to radiation alone. CCRT acts as a radiosensitizer, enhancing the destruction of tumor cells. **Why other options are incorrect:** * **Option B (Surgery):** Radical hysterectomy with pelvic lymphadenectomy is generally reserved for Stage IA to IB1 (tumors <2 cm). For IB2 and above, surgery often requires adjuvant radiation anyway due to high-risk features, leading to "dual-modality" morbidity (increased complications from both surgery and radiation). * **Option C (NACT):** Neoadjuvant chemotherapy followed by radiotherapy is not the standard of care and has not shown superiority over primary CCRT. * **Option D (Radiotherapy alone):** Radiotherapy alone is less effective than CCRT. It is only considered if the patient cannot tolerate chemotherapy. **High-Yield Pearls for NEET-PG:** * **Stage IA1:** Simple hysterectomy (or conization if fertility is desired). * **Stage IB1/IIA1:** Radical Hysterectomy (Wertheim’s) OR Radiotherapy. * **Stage IB3/IIA2 and above:** Concurrent Chemoradiation (CCRT) is the gold standard. * **Drug of choice for CCRT:** Weekly **Cisplatin**. * **Most common cause of death:** Uremia due to bilateral ureteric obstruction.

Question 605: According to the FIGO staging for endometrial carcinoma, which stage includes involvement of paraaortic lymph nodes?

A. Stage IIIb
B. Stage IIIc (Correct Answer)
C. Stage IVa
D. Stage IVb

Explanation: **Explanation:** The staging of endometrial carcinoma follows the **FIGO (2023/2009) surgical staging system**. The correct answer is **Stage IIIc**, which specifically denotes metastasis to the pelvic and/or para-aortic lymph nodes. * **Why Stage IIIc is correct:** Stage III represents local and/or regional spread of the tumor. It is subdivided into: * **IIIc1:** Metastasis to pelvic lymph nodes only. * **IIIc2:** Metastasis to **paraaortic lymph nodes**, with or without pelvic node involvement. * The presence of nodal involvement significantly changes the prognosis and dictates the need for adjuvant radiation or chemotherapy. * **Analysis of Incorrect Options:** * **Stage IIIb:** Refers to vaginal and/or parametrial involvement. * **Stage IVa:** Refers to tumor invasion of the bladder and/or bowel mucosa. * **Stage IVb:** Refers to distant metastasis, including intra-abdominal disease (omental) or inguinal lymph nodes (which are considered distant, unlike pelvic/paraaortic nodes). **High-Yield Clinical Pearls for NEET-PG:** * **Surgical Staging:** Endometrial cancer is primarily staged **surgically** (unlike cervical cancer, which was traditionally clinical but is now a hybrid). * **Most Common Histology:** Endometrioid adenocarcinoma is the most common type. * **Sentinel Lymph Node (SLN) Mapping:** This is increasingly used in early-stage disease to reduce the morbidity of complete lymphadenectomy while accurately identifying Stage IIIc disease. * **Red Flag:** Any postmenopausal bleeding must be investigated via endometrial biopsy or fractional curettage to rule out malignancy.

Question 606: What is the most common cause of cervical neoplasia?

A. Human Papillomavirus (HPV) type 6
B. Human Papillomavirus (HPV) type 11
C. Human Papillomavirus (HPV) type 16 (Correct Answer)
D. Human Herpesvirus (HHV)

Explanation: **Explanation:** The primary etiological factor in the development of cervical neoplasia (both squamous cell carcinoma and adenocarcinoma) is persistent infection with **High-Risk Human Papillomavirus (hrHPV)**. **Why Option C is correct:** Among the high-risk types, **HPV 16** is the most potent and prevalent globally. It is responsible for approximately **50-60%** of all cervical cancers. HPV 16 produces E6 and E7 oncoproteins, which degrade the p53 and pRb tumor suppressor proteins, respectively, leading to uncontrolled cell cycle progression and malignant transformation. **Why other options are incorrect:** * **Options A & B (HPV 6 and 11):** These are classified as **Low-Risk HPV** types. They are primarily associated with benign lesions such as Condyloma Acuminata (genital warts) and Recurrent Respiratory Papillomatosis. They rarely cause malignancy. * **Option D (HHV):** Human Herpesviruses (like HSV-2) were once thought to be involved, but they are now considered "co-factors" or bystanders rather than the primary causative agent of cervical neoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **HPV 16:** Most common cause of Squamous Cell Carcinoma (SCC). * **HPV 18:** Second most common type (10-15%) and has a strong association with **Adenocarcinoma**. * **Screening:** The transformation zone is the most common site for cervical neoplasia. * **Vaccination:** The 9-valent vaccine (Gardasil 9) covers types 6, 11, 16, 18, 31, 33, 45, 52, and 58. * **Most common symptom:** Post-coital bleeding is the classic clinical presentation of cervical cancer.

Question 607: A 23-year-old patient is diagnosed with stage IA malignant ovarian germ cell tumor. What is the standard treatment?

A. Unilateral oophorectomy
B. Bilateral oophorectomy and hysterectomy
C. Unilateral oophorectomy followed by chemotherapy (Correct Answer)
D. Ovarian biopsy followed by chemotherapy

Explanation: **Explanation:** The standard management for Malignant Ovarian Germ Cell Tumors (MOGCTs) differs significantly from epithelial ovarian cancer because MOGCTs are typically unilateral, occur in young women, and are highly chemosensitive. **Why Option C is Correct:** For a 23-year-old with Stage IA MOGCT, the goal is to preserve fertility while ensuring oncological safety. The standard treatment is **Fertility-Sparing Surgery (Unilateral Salpingo-oophorectomy)** followed by **adjuvant chemotherapy** (typically the BEP regimen: Bleomycin, Etoposide, and Cisplatin). Even in Stage I, most MOGCTs (except for Grade 1 Immature Teratoma and Stage IA Dysgerminoma) require chemotherapy due to their aggressive nature and high risk of occult metastasis. **Why Other Options are Incorrect:** * **Option A:** Unilateral oophorectomy alone is insufficient for most MOGCTs (except Stage IA Dysgerminoma or Grade 1 Immature Teratoma) as the recurrence risk is high without systemic therapy. * **Option B:** Bilateral oophorectomy and hysterectomy is overly aggressive for a young patient and is generally reserved for postmenopausal women or advanced epithelial cancers. * **Option C:** Ovarian biopsy is contraindicated in suspected ovarian malignancy as it can cause "spillage" of tumor cells, upstaging the disease from Stage I to Stage IC. **NEET-PG High-Yield Pearls:** * **Most common MOGCT:** Dysgerminoma (associated with LDH marker). * **Tumor Markers:** Yolk Sac Tumor (AFP), Choriocarcinoma (hCG), Dysgerminoma (LDH/PLAP). * **Chemosensitivity:** MOGCTs are the most chemosensitive solid tumors in gynaecology. * **Exception to Chemo:** Stage IA Dysgerminoma and Stage I Grade 1 Immature Teratoma can be managed with surgery and observation alone.

Question 608: CA-125 levels are elevated in which of the following conditions?

A. Endometriosis
B. Adenomyosis
C. Both Endometriosis and Adenomyosis (Correct Answer)
D. None of the above

Explanation: **Explanation:** CA-125 (Cancer Antigen 125) is a high-molecular-weight glycoprotein produced by derivatives of the **coelomic epithelium**, which includes the lining of the fallopian tubes, endometrium, and endocervix, as well as the pleura and peritoneum. **Why Option C is Correct:** CA-125 is not a specific marker for ovarian cancer; rather, it is a marker of **peritoneal irritation** and endometrial activity. * **Endometriosis:** The presence of ectopic endometrial tissue leads to chronic inflammation and irritation of the peritoneum, causing significant elevations in CA-125 levels. * **Adenomyosis:** Since the endometrial stroma and glands invade the myometrium, the increased surface area of endometrial tissue and associated inflammatory response also result in elevated serum CA-125. **Analysis of Incorrect Options:** * **Options A and B:** While CA-125 is elevated in both conditions individually, selecting only one would be incomplete. In clinical practice and NEET-PG patterns, when both conditions share a common biochemical marker, the "Both" option is the most accurate. **High-Yield Clinical Pearls for NEET-PG:** * **Normal Range:** < 35 U/mL. * **Physiological Elevations:** Menstruation (first few days), early pregnancy, and the postpartum period. * **Benign Pathological Elevations:** Pelvic Inflammatory Disease (PID), uterine fibroids, cirrhosis with ascites, and pleuritis. * **Malignant Elevations:** Most notably **Epithelial Ovarian Tumors** (especially Serous Cystadenocarcinoma). It is less reliable in mucinous tumors. * **Clinical Utility:** CA-125 is best used for **monitoring treatment response** and detecting recurrence in ovarian cancer, rather than as a primary screening tool in the general population due to its low specificity.

Question 609: Carcinoma of the endometrium with superficial inguinal lymph node involvement is classified as which stage?

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

Explanation: **Explanation:** The staging of Endometrial Carcinoma follows the **FIGO (2023)** classification. The correct answer is **Stage IV** because the involvement of **inguinal lymph nodes** represents distant metastasis. 1. **Why Stage IV is correct:** In endometrial cancer, lymphatic spread typically follows the pelvic and para-aortic chains. The **superficial inguinal nodes** are considered **distant lymph nodes** (similar to supraclavicular nodes). According to FIGO staging, involvement of distant lymph nodes, including inguinal nodes, or metastasis to distant organs (lung, liver, bone) and abdominal serosa, classifies the disease as **Stage IVB**. 2. **Why Stage III is incorrect:** Stage III involves local or regional spread within the pelvis. Stage IIIC specifically refers to metastasis to **pelvic (IIIC1)** or **para-aortic (IIIC2)** lymph nodes. Inguinal nodes are outside this regional boundary. 3. **Why Stage II is incorrect:** Stage II is limited to the **cervical stromal invasion** but does not extend beyond the uterus. 4. **Why Stage I is incorrect:** Stage I is confined to the **corpus uteri** (IA: <50% myometrial invasion; IB: ≥50% myometrial invasion). **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis:** Lungs. * **Lymphatic drainage:** The fundus drains to para-aortic nodes; the lower segment drains to pelvic nodes; however, a small portion of the fundus near the round ligament can drain directly to **inguinal nodes** (rare but diagnostic of Stage IVB). * **Most common histological type:** Endometrioid adenocarcinoma. * **Prognostic factor:** The depth of myometrial invasion and nodal involvement are the most significant predictors of survival.

Question 610: A 20-year-old female is diagnosed with a granulosa cell tumor of the ovary. Which of the following biomarkers would be most useful for patient follow-up?

A. Inhibin (Correct Answer)
B. CA50
C. CA 19-9
D. Neuron-specific enolase

Explanation: **Explanation:** Granulosa cell tumors (GCTs) are the most common type of malignant sex cord-stromal tumors. They are unique because they arise from cells that normally produce hormones in the ovarian follicle. **1. Why Inhibin is the Correct Answer:** Granulosa cells naturally secrete **Inhibin** (specifically Inhibin B) to provide negative feedback on FSH. In patients with GCTs, Inhibin levels are significantly elevated. It serves as a highly sensitive and specific tumor marker for both the **initial diagnosis** and, more importantly, for **monitoring recurrence** during follow-up. A rise in Inhibin levels often precedes clinical or radiological evidence of recurrence by several months. **2. Analysis of Incorrect Options:** * **CA50:** This is a non-specific carbohydrate antigen marker primarily associated with gastrointestinal and pancreatic malignancies, not ovarian sex cord tumors. * **CA 19-9:** This is the primary marker for **pancreatic adenocarcinoma** and is also elevated in mucinous tumors of the ovary. * **Neuron-specific enolase (NSE):** This is a marker for neuroendocrine tumors (like small cell lung cancer) and certain germ cell tumors like **dysgerminomas** or immature teratomas. **3. Clinical Pearls for NEET-PG:** * **Estrogen Production:** GCTs are "functioning tumors" that secrete estrogen. In young patients (like the one in this case), this can lead to **precocious puberty**; in older patients, it causes **postmenopausal bleeding** and increases the risk of endometrial hyperplasia/carcinoma. * **Histology:** Look for **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. * **Other Markers:** While Inhibin is the gold standard, **Anti-Müllerian Hormone (AMH)** is also a highly specific marker for GCT follow-up.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

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Ovarian Cancer

Practice Questions

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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