Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 611: Which virus is responsible for causing cervical cancer in the ectocervix?

A. HPV16 (Correct Answer)
B. HPV17
C. HPV11
D. HPV19

Explanation: **Explanation:** Human Papillomavirus (HPV) is the primary etiological agent for cervical cancer. Among the high-risk (oncogenic) types, **HPV 16** is the most prevalent, accounting for approximately 50-60% of all cervical squamous cell carcinomas (which typically arise from the ectocervix). **Why the correct answer is right:** HPV 16 and 18 are classified as high-risk because their E6 and E7 oncoproteins inhibit tumor suppressor proteins **p53** and **pRb**, respectively. This leads to uncontrolled cell proliferation and genomic instability. While HPV 16 is most associated with squamous cell carcinoma (ectocervix), HPV 18 is more frequently linked to adenocarcinoma (endocervix). **Analysis of incorrect options:** * **HPV 17 & 19:** These are not recognized as major high-risk oncogenic types in the context of cervical cancer screening or pathogenesis. * **HPV 11:** This is a **low-risk** HPV type. Along with HPV 6, it is responsible for 90% of genital warts (Condyloma acuminatum) and recurrent respiratory papillomatosis, but it rarely causes malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common HPV type in Cervical Cancer:** HPV 16 (Global and India). * **Most common HPV type in Adenocarcinoma:** HPV 18. * **Vaccination:** The Quadrivalent vaccine (Gardasil) covers types 6, 11, 16, and 18. The Nonavalent vaccine adds types 31, 33, 45, 52, and 58. * **Screening:** The Transformation Zone (TZ) is the most common site for neoplastic changes. * **Oncoprotein Mnemonic:** **E6** affects p**5**3 (6-5) and **E7** affects **R**b (7-R).

Question 612: What is the most common type of vaginal carcinoma?

A. Squamous cell carcinoma (Correct Answer)
B. Adenocarcinoma
C. Botryoid sarcoma
D. Columnar hyperplasia

Explanation: **Explanation:** **Primary vaginal cancer** is a rare malignancy, as most vaginal cancers are metastatic (usually from the cervix or endometrium). Among primary vaginal cancers, **Squamous Cell Carcinoma (SCC)** is the most common histological type, accounting for approximately **80–90%** of cases. It typically arises from the squamous epithelium lining the vagina and is most frequently seen in postmenopausal women. Like cervical cancer, it is strongly associated with high-risk **Human Papillomavirus (HPV)** infection, particularly types 16 and 18. **Analysis of Incorrect Options:** * **B. Adenocarcinoma:** This accounts for about 5–10% of cases. A specific subtype, **Clear Cell Adenocarcinoma**, is classically associated with *in utero* exposure to **Diethylstilbestrol (DES)**. * **C. Botryoid Sarcoma (Sarcoma Botryoides):** This is a subtype of embryonal rhabdomyosarcoma. While it is the most common vaginal tumor in **infants and children** (typically <5 years old), it is rare in the general population. It characteristically presents as a "cluster of grapes" protruding from the vagina. * **D. Columnar Hyperplasia:** This is a benign histological change (often related to vaginal adenosis) and is not a type of carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** The **upper 1/3rd of the posterior vaginal wall** is the most frequent location for primary vaginal SCC. * **FIGO Staging:** Vaginal cancer is staged **clinically**. * **Lymphatic Drainage:** This is a favorite exam topic. The **upper 2/3rd** drains to the **pelvic nodes** (iliac nodes), while the **lower 1/3rd** drains to the **superficial inguinal nodes**. * **Treatment:** Radiotherapy is the mainstay of treatment for most stages of vaginal cancer.

Question 613: Which tumor marker is most helpful in the follow-up of a case of epithelial carcinoma of the ovary?

A. CA-125 (Correct Answer)
B. Serum Alpha Fetoprotein
C. Serum human chorionic gonadotropin
D. Human Placental Lactogen

Explanation: **Explanation:** **CA-125 (Cancer Antigen 125)** is the gold standard tumor marker for **Epithelial Ovarian Cancer (EOC)**, which accounts for approximately 90% of all ovarian malignancies. Its primary clinical utility lies in **monitoring treatment response** and **detecting recurrence** during follow-up. A rising trend in CA-125 levels often precedes clinical or radiological evidence of disease recurrence by several months. While it is also used in the diagnostic workup (especially in postmenopausal women), its high sensitivity for serous cystadenocarcinoma makes it indispensable for longitudinal follow-up. **Analysis of Incorrect Options:** * **B. Serum Alpha-Fetoprotein (AFP):** This is the specific marker for **Yolk Sac Tumors** (Endodermal Sinus Tumors). It is also elevated in some immature teratomas and hepatocellular carcinoma. * **C. Serum human chorionic gonadotropin (hCG):** This is the marker for **Nongestational Choriocarcinoma** and is also elevated in **Dysgerminomas** (if syncytiotrophoblastic giant cells are present). * **D. Human Placental Lactogen (hPL):** This is primarily a marker for **Placental Site Trophoblastic Tumor (PSTT)**; it has no role in the management of epithelial ovarian cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Normal Value:** < 35 U/mL. * **Specificity Issue:** CA-125 can be elevated in benign conditions like endometriosis, PID, fibroids, and pregnancy, particularly in premenopausal women. * **Germ Cell Tumors:** Always remember the "Marker-Tumor" pairs: LDH for Dysgerminoma, AFP for Yolk Sac Tumor, and Inhibin B for Granulosa Cell Tumor (Sex-cord stromal). * **Struma Ovarii:** Associated with elevated Thyroxine (T4).

Question 614: Cone biopsy is indicated in all the following conditions except?

A. Indefinite diagnosis on colposcopy
B. CIN-III
C. Cervical metaplasia (Correct Answer)
D. Microinvasive carcinoma

Explanation: **Explanation:** **Cervical metaplasia** (specifically squamous metaplasia) is a **normal physiological process** occurring at the transformation zone where columnar epithelium is replaced by squamous epithelium. It is not a premalignant condition and requires no surgical intervention. Therefore, a cone biopsy—an invasive procedure—is never indicated for metaplasia. **Why other options are indications for Cone Biopsy:** * **Indefinite diagnosis on colposcopy:** If the colposcopic examination is "unsatisfactory" (e.g., the squamocolumnar junction is not fully visualized) or if there is a discrepancy between the Pap smear (high-grade) and the biopsy (low-grade), a cone biopsy is mandatory to rule out occult malignancy. * **CIN-III:** High-grade squamous intraepithelial lesions (HSIL/CIN-III) require definitive treatment to prevent progression to invasive cancer. Conization serves as both a diagnostic and therapeutic (excisional) procedure. * **Microinvasive carcinoma (Stage IA1):** Cone biopsy is the gold standard for diagnosing the depth of invasion. If the margins are clear and the depth is <3mm with no lymphovascular space invasion (LVSI), conization can also be the definitive treatment for women wishing to preserve fertility. **NEET-PG High-Yield Pearls:** * **Diagnostic vs. Therapeutic:** Conization is unique because it provides a large tissue sample for histopathology (diagnostic) while simultaneously removing the lesion (therapeutic). * **The "Rule of Discrepancy":** If Cytology (Pap) > Biopsy or Colposcopy, proceed to Cone Biopsy. * **Complications:** The most common immediate complication is **hemorrhage** (descending branch of the uterine artery); the most common long-term complication is **cervical incompetence** (leading to mid-trimester abortions) or cervical stenosis.

Question 615: What is the most common Human Papillomavirus (HPV) type responsible for cervical cancer?

A. HPV 16 (Correct Answer)
B. HPV 18
C. HPV 31
D. HPV 36

Explanation: **Explanation:** Cervical cancer is primarily caused by persistent infection with high-risk Human Papillomavirus (HPV) types. Among these, **HPV 16** is the most oncogenic and prevalent, accounting for approximately **50-60%** of all cervical squamous cell carcinomas worldwide. It has a high affinity for the transformation zone of the cervix, where its E6 and E7 oncoproteins inhibit the tumor suppressor proteins p53 and pRb, respectively, leading to malignant transformation. **Analysis of Options:** * **Option A (HPV 16):** Correct. It is the single most common type identified in cervical cancer globally. * **Option B (HPV 18):** Incorrect. While it is the second most common high-risk type (responsible for ~10-15% of cases), it is specifically associated more frequently with **adenocarcinoma** of the cervix rather than squamous cell carcinoma. * **Option C (HPV 31):** Incorrect. This is a high-risk type, but it accounts for a much smaller percentage of cases compared to 16 and 18. * **Option D (HPV 36):** Incorrect. This is generally considered a low-risk type and is not a significant driver of cervical malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common types:** HPV 16 and 18 together cause ~70% of all cervical cancers. * **Genital Warts (Condyloma Acuminata):** Caused by low-risk types **HPV 6 and 11**. * **Vaccination:** The Quadrivalent vaccine (Gardasil) covers 6, 11, 16, and 18; the Nonavalent vaccine covers five additional high-risk types (31, 33, 45, 52, 58). * **Screening:** The primary screening tool remains the Pap smear (cytology) and HPV DNA testing.

Question 616: Which lymph nodes are typically not involved in carcinoma of the endometrium?

A. Para-aortic
B. Presacral
C. Inferior mesenteric (Correct Answer)
D. Inguinal

Explanation: **Explanation:** The lymphatic drainage of the endometrium follows the arterial supply and embryonic development of the uterus. The primary drainage pathways are through the **external iliac, internal iliac, and obturator nodes**, eventually reaching the **para-aortic nodes**. **Why Inferior Mesenteric is the Correct Answer:** The **inferior mesenteric lymph nodes** drain the descending colon, sigmoid colon, and upper rectum. They are not part of the standard lymphatic drainage pathway for the female genital tract. While endometrial cancer can spread to the para-aortic nodes (near the origin of the renal vessels), it does not typically involve the inferior mesenteric chain unless there is extensive, non-anatomical intraperitoneal carcinomatosis. **Analysis of Other Options:** * **Para-aortic (A):** High-yield fact! Lymphatics from the uterine fundus follow the ovarian vessels directly to the para-aortic nodes. This is a common site for "skip metastases." * **Presacral (B):** Lymphatics from the lower uterine segment and cervix can drain via the uterosacral ligaments to the presacral nodes. * **Inguinal (C):** Though rare, involvement occurs when the tumor spreads along the **round ligament** to the superficial inguinal nodes. This is a classic "high-yield" anatomical variant for exams. **NEET-PG High-Yield Pearls:** 1. **Most common site of spread:** Direct extension to the myometrium. 2. **Most common LN involvement:** Pelvic lymph nodes (Obturator nodes are often the first involved). 3. **Sentinel Lymph Node (SLN) Mapping:** Now the preferred standard in early-stage endometrial cancer to reduce the morbidity of full lymphadenectomy. 4. **Staging:** Endometrial cancer is **surgically staged** (FIGO). Involvement of pelvic nodes is Stage IIIC1, and para-aortic nodes is Stage IIIC2.

Question 617: Which hormone is produced by an endodermal sinus tumor?

A. Both 2 & 3 (Correct Answer)
B. Alpha-1-antitrypsin
C. Alpha-fetoprotein
D. Human chorionic gonadotropin

Explanation: **Explanation:** Endodermal Sinus Tumor (EST), also known as **Yolk Sac Tumor**, is the most common malignant germ cell tumor in children and young adults. It is highly aggressive and characterized by rapid growth. **Why the correct answer is right:** Endodermal sinus tumors are derived from the primitive yolk sac. Consequently, they produce proteins normally synthesized by the fetal liver and yolk sac. * **Alpha-fetoprotein (AFP):** This is the most characteristic tumor marker for EST. It is used for diagnosis, monitoring treatment response, and detecting recurrence. * **Alpha-1-antitrypsin (A1AT):** While AFP is more famous, EST also produces Alpha-1-antitrypsin. Histologically, both these substances can be seen as eosinophilic, PAS-positive hyaline droplets within the cytoplasm of the tumor cells. **Why other options are wrong:** * **Human chorionic gonadotropin (hCG):** This is the characteristic marker for **Choriocarcinoma**. While some mixed germ cell tumors may show elevated hCG, it is not a primary product of a pure Endodermal Sinus Tumor. * **Option B and C individually:** While both are correct, the question requires selecting the option that encompasses both markers produced by the tumor. **NEET-PG High-Yield Pearls:** 1. **Schiller-Duval Bodies:** The pathognomonic histological feature of EST (resembles a primitive glomerulus). 2. **Age Group:** Typically occurs in young women (average age 18–19 years). 3. **Treatment:** Highly chemosensitive; the standard regimen is **BEP** (Bleomycin, Etoposide, and Platinum/Cisplatin). 4. **Most common site:** Ovary (in females) and Testis (in young boys).

Question 618: The CO regimen for the treatment of choriocarcinoma includes all of the following except?

A. Etoposide
B. Cisplatin (Correct Answer)
C. Methotrexate
D. Actinomycin-D

Explanation: The correct answer is **Cisplatin**. ### **Explanation** The standard of care for high-risk Gestational Trophoblastic Neoplasia (GTN), including choriocarcinoma, is the **EMA-CO regimen**. This multi-agent chemotherapy protocol is preferred due to its high efficacy and relatively manageable toxicity profile. The acronym **EMA-CO** stands for: * **E** – Etoposide * **M** – Methotrexate (with Leucovorin rescue) * **A** – Actinomycin-D (Dactinomycin) * **C** – Cyclophosphamide * **O** – Oncovin (Vincristine) **Cisplatin** is not a component of the primary EMA-CO regimen. It is typically reserved for **refractory or recurrent** cases as part of salvage therapy regimens, such as **EMA-EP** (where Etoposide and Cisplatin replace Cyclophosphamide and Vincristine) or **TP/TE** (Paclitaxel, Cisplatin/Etoposide). ### **Analysis of Options** * **A. Etoposide:** A key component of the "EMA" portion, acting as a topoisomerase II inhibitor. * **C. Methotrexate:** The backbone of GTN treatment; used as monotherapy in low-risk cases and as part of EMA-CO for high-risk cases. * **D. Actinomycin-D:** An antitumor antibiotic used in both low-risk (as a second-line single agent) and high-risk (EMA-CO) protocols. ### **High-Yield Clinical Pearls for NEET-PG** 1. **WHO Scoring:** The choice between single-agent (Methotrexate) and multi-agent (EMA-CO) therapy is based on the **WHO Modified FIGO Scoring System**. A score of **≥7** indicates high-risk disease requiring EMA-CO. 2. **Most Common Site of Metastasis:** The **Lungs** (80%), followed by the vagina (30%). 3. **Tumor Marker:** Serum **β-hCG** is the gold standard for diagnosis, monitoring treatment response, and detecting recurrence. 4. **Vincristine Side Effect:** Peripheral neuropathy is a common dose-limiting toxicity of the "O" (Oncovin) in EMA-CO.

Question 619: Which of the following does not belong to gestational trophoblastic tumors?

A. Chorioangioma (Correct Answer)
B. Placental site trophoblastic tumor
C. Choriocarcinoma
D. Hydatidiform mole

Explanation: ### Explanation **Gestational Trophoblastic Disease (GTD)** refers to a group of pregnancy-related tumors arising from the abnormal proliferation of trophoblastic tissue (cytotrophoblast, syncytiotrophoblast, and intermediate trophoblast). **Why Chorioangioma is the correct answer:** **Chorioangioma** is a benign **vascular tumor** of the placenta, arising from fetal blood vessels (mesenchymal origin). It is the most common benign tumor of the placenta but is **not** a trophoblastic neoplasm. Clinically, large chorioangiomas can lead to polyhydramnios, fetal hydrops, and high-output cardiac failure due to arteriovenous shunting. **Analysis of Incorrect Options:** * **Hydatidiform Mole (Option D):** This is the most common form of GTD. It is categorized as premalignant and includes complete and partial moles. * **Choriocarcinoma (Option C):** A highly malignant, epithelial tumor composed of syncytiotrophoblasts and cytotrophoblasts. It is characterized by early hematogenous spread (most commonly to the lungs) and high hCG levels. * **Placental Site Trophoblastic Tumor (PSTT) (Option B):** A rare, slow-growing tumor arising from **intermediate trophoblasts** at the placental site. Unlike other GTDs, it produces low levels of hCG and is relatively resistant to chemotherapy (surgery is the primary treatment). **NEET-PG High-Yield Pearls:** * **GTN Classification:** Gestational Trophoblastic Neoplasia (GTN) includes Invasive mole, Choriocarcinoma, PSTT, and Epithelioid Trophoblastic Tumor (ETT). * **Tumor Marker:** hCG is the primary marker for diagnosis and monitoring, except in PSTT where **Human Placental Lactogen (hPL)** is more characteristic. * **Snowstorm Appearance:** Classic ultrasound finding for a complete hydatidiform mole. * **Theca Lutein Cysts:** Often seen bilaterally in moles due to high hCG levels.

Question 620: A patient with carcinoma endometrium has >50% myometrial invasion and vaginal metastasis. Peritoneal seedings are positive. What is the clinical stage?

A. Stage IIC1
B. Stage IIIC1 (Correct Answer)
C. Stage IIIC2
D. Stage IIIC3

Explanation: **Explanation:** The staging of endometrial carcinoma is based on the **FIGO 2023 Staging System** (which updated the 2009 criteria). 1. **Why Stage IIIC1 is correct:** In the updated FIGO 2023 classification, the presence of **peritoneal metastasis** (seedings) is the defining feature for **Stage IIIC1**. * **Stage IIIA:** Involves the uterine serosa or adnexa. * **Stage IIIB:** Involves vaginal or parametrial metastasis. * **Stage IIIC:** Specifically denotes **peritoneal metastasis**. * *Note:* In the previous 2009 staging, peritoneal washings were removed from staging, but the 2023 update explicitly categorizes peritoneal spread as Stage IIIC1. 2. **Why other options are incorrect:** * **Stage IIC1:** This stage does not exist in the FIGO classification for endometrial cancer. * **Stage IIIC2:** This stage is reserved for metastasis to the **pelvic lymph nodes**. * **Stage IIIC3:** This stage is reserved for metastasis to the **paraaortic lymph nodes** (with or without pelvic node involvement). **High-Yield Clinical Pearls for NEET-PG:** * **Myometrial Invasion:** >50% invasion (Stage IB) is a significant prognostic factor but is "upstaged" by distant spread (vaginal/peritoneal). * **Vaginal Metastasis:** Isolated vaginal involvement is Stage IIIB. However, when peritoneal seedings are present, the higher stage (IIIC1) takes precedence. * **Lymphovascular Space Invasion (LVSI):** This is now incorporated into the 2023 staging (Stage II) if extensive. * **Most Common Site of Spread:** Endometrial cancer primarily spreads via direct extension, but lymphatic spread to pelvic and paraaortic nodes is a key surgical staging component.

Practice by Chapter

Cervical Cancer

Practice Questions

Endometrial Cancer

Practice Questions

Ovarian Cancer

Practice Questions

Vulvar and Vaginal Cancer

Practice Questions

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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