Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 631: What is the most common histological subtype of endometrial cancer?

A. Mucinous carcinoma
B. Clear cell carcinoma
C. Squamous cell carcinoma
D. Endometrioid adenocarcinoma (Correct Answer)

Explanation: **Explanation:** Endometrial cancer is the most common gynecological malignancy in developed countries and is broadly classified into two types (Bokhman’s classification). **Endometrioid adenocarcinoma** is the correct answer as it accounts for approximately **75–80%** of all cases. It is classified as **Type I** endometrial cancer, which is estrogen-dependent, arises from endometrial hyperplasia, and generally carries a favorable prognosis. **Analysis of Options:** * **A. Mucinous carcinoma:** This is a rare subtype (approx. 1–5% of cases). It is usually low-grade and resembles endocervical tissue but is not the most common. * **B. Clear cell carcinoma:** This is a **Type II** (estrogen-independent) endometrial cancer. It is highly aggressive, occurs in older postmenopausal women, and accounts for less than 5% of cases. * **C. Squamous cell carcinoma:** Primary squamous cell carcinoma of the endometrium is extremely rare. Squamous differentiation is more commonly seen as a component within an endometrioid adenocarcinoma (formerly called adenoacanthoma). **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Obesity (most significant due to peripheral conversion of androstenedione to estrone), nulliparity, late menopause, and Tamoxifen use. * **Protective Factors:** Combined oral contraceptive pills (COCPs) and smoking (though smoking increases the risk of cervical cancer, it decreases estrogen levels, thus lowering endometrial cancer risk). * **Precursor Lesion:** Atypical Endometrial Hyperplasia (also known as Endometrial Intraepithelial Neoplasia - EIN). * **Lynch Syndrome (HNPCC):** The most common extracolonic malignancy in women with Lynch syndrome is endometrial cancer.

Question 632: A 17-year-old girl presents with an ovarian tumor. Ultrasound shows a predominant solid component. Serum markers are negative for CA-125 and AFP, but Alkaline Phosphatase is elevated. What is the most likely diagnosis?

A. Dysgerminoma (Correct Answer)
B. Endodermal sinus tumor
C. Malignant teratoma
D. Mucinous cystadenoma

Explanation: **Explanation:** The clinical presentation points toward a **Dysgerminoma**, the most common malignant germ cell tumor (GCT) in young women. **Why Dysgerminoma is correct:** * **Age Profile:** It typically occurs in adolescents and young adults (under 30). * **Tumor Markers:** Dysgerminoma is uniquely characterized by elevated **Serum Alkaline Phosphatase (ALP)** and **LDH**. It does not typically produce AFP or hCG (unless syncytiotrophoblastic giant cells are present). * **Imaging:** On ultrasound, it appears as a solid, lobulated mass with fibrovascular septa. **Why other options are incorrect:** * **Endodermal Sinus Tumor (Yolk Sac Tumor):** This is highly aggressive and characteristically shows significantly elevated **Alpha-fetoprotein (AFP)**. Histologically, it features Schiller-Duval bodies. * **Malignant Teratoma (Immature Teratoma):** These usually contain elements from all three germ layers (often neuroepithelium). While they can have solid components, they are often associated with elevated AFP or LDH, but ALP is not a specific marker for them. * **Mucinous Cystadenoma:** This is a benign epithelial tumor, usually seen in older age groups, and is typically cystic/multilocular rather than predominantly solid. **High-Yield Clinical Pearls for NEET-PG:** * **Most common** malignant germ cell tumor in pregnancy and in patients with **gonadal dysgenesis** (Swyer Syndrome). * **Radiosensitivity:** Dysgerminoma is the most radiosensitive ovarian tumor, though fertility-sparing surgery followed by chemotherapy (BEP regimen) is the standard of care. * **Microscopy:** Look for "large polygonal cells with clear cytoplasm (due to glycogen) and central nuclei, separated by fibrous septa infiltrated with **lymphocytes**."

Question 633: What is the first symptom of vulvar cancer?

A. Pain
B. Pruritus (Correct Answer)
C. Ulceration
D. Bloody discharge

Explanation: **Explanation:** Vulvar cancer is the fourth most common gynecological malignancy, primarily affecting postmenopausal women. **1. Why Pruritus is Correct:** The most common and typically the **first symptom** of vulvar cancer is **long-standing pruritus (itching)**. This is often associated with underlying precursor conditions such as **Lichen Sclerosus** or Vulvar Intraepithelial Neoplasia (VIN). The chronic irritation and inflammatory changes in the vulvar skin lead to itching long before a visible mass or ulcer develops. In many cases, patients may have a history of using topical steroids for years to manage this pruritus before a malignancy is diagnosed. **2. Why Other Options are Incorrect:** * **Pain:** This is usually a late feature, occurring when the tumor becomes large, secondarily infected, or involves deep nerve endings. * **Ulceration/Mass:** While a vulvar lump or ulcer is the most common **physical sign** on examination, it usually appears after the initial phase of pruritus. * **Bloody discharge:** This occurs only when the tumor undergoes surface necrosis or significant erosion, representing more advanced local disease. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (90%). * **Most common site:** Labia majora. * **Staging:** Vulvar cancer is staged **surgically** (FIGO). * **Route of spread:** Primarily via **lymphatics**. The "Sentinel Lymph Node" biopsy is crucial for early-stage disease. * **Risk Factors:** HPV 16 & 18 (in younger patients) and Lichen Sclerosus (in elderly patients).

Question 634: Uterine sarcomas constitute about what percentage of all malignant growths of the uterus?

A. 5% (Correct Answer)
B. 10%
C. 15%
D. 20%

Explanation: **Explanation:** Uterine sarcomas are rare, aggressive mesenchymal tumors that account for approximately **3% to 5%** of all uterine malignancies. The vast majority (95%) of uterine cancers are epithelial in origin (Endometrial Adenocarcinomas). Because sarcomas arise from the myometrium or the connective tissue stroma of the endometrium rather than the lining itself, they are significantly less common but carry a much poorer prognosis. * **Why 5% is correct:** Standard oncological data and major textbooks (like Williams Gynecology) categorize uterine sarcomas as rare entities, consistently citing an incidence of less than 5%. The most common subtypes include Leiomyosarcoma (LMS), Endometrial Stromal Sarcoma (ESS), and High-grade Undifferentiated Sarcoma. * **Why 10%, 15%, and 20% are incorrect:** These percentages significantly overestimate the prevalence. While endometrial carcinoma is the most common gynecologic malignancy in developed countries, the mesenchymal (sarcoma) component remains a small fraction. Choosing these higher values would confuse sarcomas with the incidence of specific subtypes of adenocarcinomas or benign conditions like leiomyomas. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most Common Subtype:** Leiomyosarcoma (LMS) is the most frequent uterine sarcoma. 2. **Carcinosarcoma (MMMT):** Previously classified as a sarcoma, it is now considered a **metaplastic carcinoma** (epithelial origin) and is staged like endometrial cancer. 3. **Clinical Presentation:** Rapidly enlarging uterus in a postmenopausal woman, often presenting with abnormal uterine bleeding (AUB) and pelvic pain. 4. **Risk Factors:** Prior pelvic radiation is a significant risk factor for developing uterine sarcomas later in life. 5. **Diagnosis:** Often made post-operatively after a presumed surgery for "benign" fibroids.

Question 635: What is the most common type of vaginal carcinoma?

A. Squamous cell carcinoma (Correct Answer)
B. Adenocarcinoma
C. Transitional cell carcinoma
D. Columnar cell carcinoma

Explanation: **Explanation:** **Primary vaginal cancer** is a rare malignancy, accounting for only 1–2% of all gynecological cancers. The diagnosis requires that the primary site is the vagina and that the cervix and vulva are clinically uninvolved. **1. Why Squamous Cell Carcinoma (SCC) is Correct:** Squamous cell carcinoma is the most common histological type, accounting for approximately **80–90%** of all primary vaginal cancers. It typically arises from the squamous epithelium lining the vaginal vault. It is most frequently seen in postmenopausal women (mean age 60–70 years) and is strongly associated with **High-risk Human Papillomavirus (HPV)** infection, particularly types 16 and 18. **2. Why the Other Options are Incorrect:** * **Adenocarcinoma:** This is the second most common type (approx. 10%). It is historically significant due to its association with **in-utero Diethylstilbestrol (DES) exposure**, which leads specifically to **Clear Cell Adenocarcinoma**. * **Transitional cell carcinoma:** This is an extremely rare variant in the vagina, more commonly associated with the urinary tract (bladder/urethra). * **Columnar cell carcinoma:** This is not a standard pathological classification for primary vaginal cancer. While the upper vagina develops from Müllerian ducts (which have columnar epithelium), malignancies arising here are classified as adenocarcinomas. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** The **posterior wall of the upper one-third** of the vagina is the most frequent location for SCC. * **Lymphatic Drainage:** This is a frequent exam topic. The **upper 2/3** drains to the **iliac nodes** (internal, external, and common), while the **lower 1/3** drains to the **superficial inguinal nodes**. * **Staging:** Unlike many other gynae-cancers, vaginal cancer is staged **clinically** (FIGO staging). * **Treatment:** Radiotherapy is the primary treatment modality for most stages of vaginal cancer.

Question 636: Carcinoma of the cervix extends to the lateral pelvic wall in which stage?

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

Explanation: **Explanation:** The staging of cervical cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) classification**, which is primarily clinical. **Why Stage II is correct:** Stage II indicates that the carcinoma has extended beyond the uterus but has **not** reached the lower third of the vagina or the pelvic wall. Specifically: * **Stage IIA:** Involvement of the upper two-thirds of the vagina (no parametrial involvement). * **Stage IIB:** Involvement of the **parametria**, extending laterally toward the pelvic wall, but **not reaching it**. *Note: There is a common point of confusion in medical exams regarding the phrasing "extends to." In FIGO staging, Stage II involves the parametrium, while Stage III is defined by the extension actually reaching the pelvic wall.* **Why other options are incorrect:** * **Stage I:** The carcinoma is strictly confined to the cervix (macroscopic or microscopic). * **Stage III:** This is the stage where the tumor **reaches the pelvic wall**, involves the lower third of the vagina, or causes hydronephrosis/non-functioning kidney. (Stage IIIB specifically denotes extension to the pelvic wall). * **Stage IV:** Represents advanced disease extending beyond the true pelvis or involving the mucosa of the bladder or rectum (IVA) or distant metastasis (IVB). **High-Yield Clinical Pearls for NEET-PG:** * **Most common stage at presentation:** Stage IIB (Parametrial involvement). * **Hydronephrosis:** Automatically upgrades the disease to **Stage IIIC** (if nodes are involved) or **Stage IIIB** (due to pelvic wall pressure), regardless of tumor size. * **Treatment Shift:** Stage IIA1 and below are generally surgical (Wertheim’s Hysterectomy); Stage IIA2 and above (including IIB) are treated with **Concurrent Chemoradiotherapy (CCRT)**, which is the gold standard for locally advanced disease. * **Parametrial involvement** is the clinical hallmark that distinguishes Stage IIB from Stage IIA.

Question 637: What is the karyotype of a complete mole?

A. 46 XY
B. 46 XX (Correct Answer)
C. 69 XXX
D. 69 XXX

Explanation: **Explanation:** Hydatidiform moles are categorized into **Complete** and **Partial** moles based on their genetic composition and histopathology. **Why 46 XX is the correct answer:** A **Complete Mole** is purely paternal in origin (androgenetic). It occurs when an "empty egg" (an ovum with an absent or inactivated nucleus) is fertilized by a single sperm. The paternal 23X chromosomes then duplicate to form a **46 XX** diploid set. This process is called **monospermic fertilization** and accounts for approximately 90% of complete moles. While 46 XY can occur via **dispermic fertilization** (two sperm entering an empty egg), 46 XX is the most frequent karyotype encountered clinically. **Analysis of Incorrect Options:** * **46 XY (Option A):** While possible in a complete mole through dispermic fertilization, it is less common than 46 XX. * **69 XXX / 69 XXY (Options C & D):** These represent **triploidy**, which is the hallmark of a **Partial Mole**. Partial moles result from the fertilization of a normal haploid ovum (23X) by two sperm (or one diploid sperm), leading to 69 chromosomes. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Complete mole = Paternal only; Partial mole = Maternal + Paternal. * **Fetal Tissue:** Absent in Complete moles; Present in Partial moles. * **Malignant Potential:** Complete moles have a higher risk (15–20%) of progressing to Choriocarcinoma compared to Partial moles (<5%). * **Histology:** "Bunch of grapes" appearance with diffuse hydropic swelling and circumferential trophoblastic proliferation is characteristic of Complete moles. * **p57 Expression:** Complete moles are **p57 negative** (since p57 is a maternally expressed gene), whereas Partial moles are p57 positive.

Question 638: A female patient has adenocarcinoma of the uterus along with sarcoma of the uterus. What is this condition known as?

A. Homologous sarcoma
B. Sarcoma uterus
C. Mixed mullerian tumor (Correct Answer)
D. Heterologous sarcoma

Explanation: **Explanation:** The correct answer is **Mixed Mullerian Tumor**, specifically known as **Malignant Mixed Mullerian Tumor (MMMT)** or **Carcinosarcoma**. ### 1. Why the correct answer is right A Mixed Mullerian Tumor is a high-grade neoplasm characterized by a **biphasic** appearance: it contains both a malignant epithelial component (**adenocarcinoma**) and a malignant mesenchymal component (**sarcoma**). Current molecular evidence suggests these are "metaplastic" carcinomas, where the epithelial cells undergo a transformation into sarcomatous elements. Because it contains both tissue types, it is termed "mixed." ### 2. Why the other options are wrong * **Homologous Sarcoma:** This refers to a uterine sarcoma where the malignant tissue is native to the uterus (e.g., Leiomyosarcoma or Endometrial Stromal Sarcoma). It does not contain an adenocarcinoma component. * **Sarcoma Uterus:** This is a broad category of mesenchymal tumors. While MMMT has a sarcomatous element, the term "Sarcoma" alone fails to account for the co-existing adenocarcinoma required by the question. * **Heterologous Sarcoma:** This refers to a sarcoma where the malignant tissue is foreign to the uterus (e.g., Rhabdomyosarcoma containing skeletal muscle or Chondrosarcoma containing cartilage). While an MMMT can be heterologous, the defining feature of the biphasic tumor described is its "mixed" nature. ### 3. Clinical Pearls for NEET-PG * **Classification:** MMMTs are now clinically staged and treated as high-grade **Endometrial Carcinomas** (Stage I-IV FIGO staging) rather than true sarcomas. * **Risk Factors:** Postmenopausal age, obesity, and a history of **pelvic radiation** (a classic high-yield association). * **Clinical Presentation:** Often presents as a large, polypoid mass protruding through the cervical os in an elderly woman with postmenopausal bleeding. * **Prognosis:** Very aggressive with a high propensity for lymphatic spread.

Question 639: What is the commonest tumor of the ovary occurring in a young woman?

A. Immature teratoma
B. Yolk sac tumor
C. Endometrioid tumor
D. Dysgerminoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **Dysgerminoma**. **1. Why Dysgerminoma is correct:** Germ Cell Tumors (GCTs) are the most common ovarian neoplasms in children and young women (under age 30). Among malignant GCTs, **Dysgerminoma** is the most frequent subtype, accounting for approximately 50% of cases. It is the female counterpart of the testicular seminoma. It typically presents in the second and third decades of life and is highly radiosensitive and chemosensitive. **2. Why the other options are incorrect:** * **Immature Teratoma:** While this is a common malignant GCT in young women, it is less frequent than Dysgerminoma. It is characterized by the presence of primitive neuroectodermal tissue. * **Yolk Sac Tumor (Endodermal Sinus Tumor):** This is the second most common malignant GCT. It is highly aggressive and characterized by elevated **AFP** levels and the presence of **Schiller-Duval bodies** on histology. * **Endometrioid Tumor:** This is a subtype of Surface Epithelial Tumors. These occur predominantly in peri-menopausal or post-menopausal women (ages 50–60) and are often associated with endometriosis. **3. NEET-PG High-Yield Pearls:** * **Most common ovarian tumor overall:** Serous Cystadenoma (Benign). * **Most common malignant ovarian tumor overall:** Serous Cystadenocarcinoma (Epithelial). * **Tumor Marker for Dysgerminoma:** LDH (Lactate Dehydrogenase) and sometimes hCG. * **Association:** Dysgerminomas are associated with gonadal dysgenesis (Swyer Syndrome). * **Bilateralism:** Dysgerminoma is the only malignant GCT that is frequently bilateral (10-15%).

Question 640: Which of the following is a common benign epithelial ovarian tumor?

A. Serous cystadenoma (Correct Answer)
B. Mucinous cystadenoma
C. Brenner tumor
D. Ovarian fibroma

Explanation: **Explanation:** Ovarian tumors are classified based on their tissue of origin: Surface Epithelium, Germ Cells, or Sex Cord-Stroma. Epithelial tumors are the most common type of ovarian neoplasms, accounting for approximately 65–70% of all ovarian tumors. **Why Serous Cystadenoma is the correct answer:** **Serous cystadenoma** is the most common benign epithelial ovarian tumor. It typically presents as a unilocular cyst filled with clear (serous) fluid and lined by ciliated columnar epithelium (resembling the fallopian tube). It accounts for about 20–25% of all benign ovarian neoplasms. **Analysis of Incorrect Options:** * **B. Mucinous cystadenoma:** While also a common benign epithelial tumor, it is less frequent than the serous variety. These are characterized by large, multilocular cysts lined by mucus-secreting cells (resembling endocervical or intestinal epithelium). * **C. Brenner tumor:** This is an uncommon epithelial tumor characterized by "Walthard cell nests" (transitional epithelium resembling the bladder). Most are benign, but they are significantly rarer than serous or mucinous types. * **D. Ovarian fibroma:** This is a **Sex Cord-Stromal tumor**, not an epithelial tumor. It is a solid, benign tumor composed of bundles of spindle-shaped fibroblasts. **High-Yield NEET-PG Pearls:** * **Most common ovarian tumor overall:** Benign Cystic Teratoma (Dermoid cyst) — *Note: Serous cystadenoma is the most common epithelial tumor.* * **Most common malignant ovarian tumor:** Serous Cystadenocarcinoma. * **Psammoma bodies:** Classically seen in Serous tumors (both benign and malignant). * **Meigs Syndrome:** Triad of Ovarian Fibroma, Ascites, and Pleural Effusion. * **Tumor Marker:** CA-125 is the standard marker for epithelial ovarian cancers.

Practice by Chapter

Cervical Cancer

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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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