Gynecologic Oncology — MCQs

A woman presents with a 12-week pregnancy complaining of excessive vomiting and mild vaginal bleeding for two weeks. Her fundal height measures 16 weeks, and the cervical os is closed. An ultrasound reveals a snowstorm appearance in part of the uterus along with a fetus measuring 10 weeks crown-rump length. Fetal heart activity is absent. What is the best management option?

Q648Medium

Which of the following is the most common form of persistent trophoblastic disease that follows a non-molar pregnancy?

Q649Medium

A 38-year-old female has a Pap smear suggestive of HSIL. Colposcopy-directed biopsy can reveal all of the following, EXCEPT:

Q650Medium

A 23-year-old female presents with pelvic pain and is found to have a 3 cm ovarian mass on the left ovary. Grossly, the mass consists of multiple cystic spaces. Histologically, these cysts are lined by tall columnar epithelium, with some of the cells being ciliated. What is your diagnosis of this ovarian tumor, which histologically recapitulates the histology of the fallopian tubes?

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 641: What is the treatment of choice for hydatiform mole with a uterine size of 28 weeks?

A. Suction evacuation (Correct Answer)
B. Intra-amniotic saline followed by oxytocin
C. Evacuation by misoprostol and Mifepristone
D. Methotrexate administration

Explanation: **Explanation:** The treatment of choice for a hydatidiform mole, regardless of the uterine size, is **Suction Evacuation**. This is the gold standard because it allows for rapid, controlled removal of molar tissue while minimizing the risk of uterine perforation and excessive blood loss. Even in cases where the uterus is significantly enlarged (e.g., 28 weeks), suction evacuation is preferred over medical or surgical induction. **Analysis of Options:** * **Option A (Correct):** Suction evacuation is the definitive management. A large-bore cannula (10–12 mm) is used. It is recommended to start an Oxytocin infusion *after* the evacuation has begun to ensure uterine contraction and reduce hemorrhage. * **Option B & C (Incorrect):** Medical induction using saline, oxytocin, or prostaglandins (Misoprostol/Mifepristone) is **contraindicated**. These methods increase the risk of uterine contractions forcing trophoblastic tissue into the systemic circulation, potentially leading to **trophoblastic embolization** and respiratory distress. Furthermore, medical methods often result in incomplete evacuation. * **Option D (Incorrect):** Methotrexate is a chemotherapeutic agent used for Gestational Trophoblastic Neoplasia (GTN) or ectopic pregnancy. It is not the primary treatment for an evacuation of a molar pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** "Snowstorm appearance" on USG and disproportionately high Beta-hCG levels. * **Theca Lutein Cysts:** Often associated with large moles; these usually regress spontaneously after evacuation and do not require surgery. * **Follow-up:** Essential to monitor Beta-hCG levels weekly until three consecutive negatives are achieved to rule out progression to Choriocarcinoma. * **Hysterectomy:** May be considered an alternative to suction evacuation only in women >40 years who have completed their family, to reduce the risk of post-molar GTN.

Question 642: All are signs of inoperability of carcinoma of the cervix except?

A. Carcinoma of the cervix extending to the parametrium (Correct Answer)
B. Presence of extrapelvic metastasis
C. Involvement of the bladder
D. Extensive infiltration of the vagina

Explanation: **Explanation:** The management of cervical cancer is primarily determined by its **FIGO Stage**. In gynecologic oncology, the dividing line between surgical management and primary radiotherapy is **Stage IIB**. **Why Option A is the correct answer:** Carcinoma extending to the parametrium defines **Stage IIB**. While Stage IIB is generally treated with primary chemoradiation, it is **not an absolute sign of inoperability** in all clinical contexts. In specific cases (especially "early" IIB or after neoadjuvant chemotherapy in some protocols), surgery may still be considered. More importantly, in the context of NEET-PG questions, the other three options represent much more advanced stages (Stage IVA or IVB) which are universally considered inoperable for curative surgery. **Analysis of Incorrect Options:** * **B. Extrapelvic metastasis:** This represents **Stage IVB**. Surgery is not curative when the disease has spread beyond the pelvis (e.g., supraclavicular nodes, lungs). * **C. Involvement of the bladder:** This represents **Stage IVA**. Direct invasion of the bladder or rectal mucosa indicates locally advanced disease where standard radical hysterectomy is technically impossible and oncologically insufficient. * **D. Extensive infiltration of the vagina:** If the carcinoma involves the **lower third of the vagina**, it is **Stage IIIA**. Involvement of the lower third is a classic sign of inoperability as it precludes obtaining clear surgical margins. **High-Yield Clinical Pearls for NEET-PG:** * **Operable Stages:** IA1, IA2, IB1, IB2, and IIA1. * **Standard Surgery:** Wertheim’s Radical Hysterectomy (Type III/C2) is the treatment of choice for early-stage disease. * **Inoperable Stages:** Generally Stage IIB through IVB. * **Gold Standard Treatment for Stage IIB-IVA:** Concurrent Chemoradiotherapy (CCRT) using Cisplatin. * **Most common cause of death:** Uremia due to ureteric obstruction.

Question 643: What is the percentage change of cystic glandular hyperplasia turning to malignancy?

A. 0.10%
B. 2%
C. 1% (Correct Answer)
D. 10%

Explanation: **Explanation:** The risk of progression from endometrial hyperplasia to malignancy is primarily determined by the presence of **cellular atypia**. This classification is based on the classic **Kurman’s criteria**, which is a high-yield topic for NEET-PG. **1. Why Option C (1%) is Correct:** Cystic glandular hyperplasia (also known as **Simple Hyperplasia without atypia**) is characterized by an increase in the number of glands which may be dilated (cystic), but the cells lining these glands do not show any nuclear features of malignancy. Because there is no atypia, the risk of progression to endometrial carcinoma is very low, historically cited as **1%**. **2. Analysis of Incorrect Options:** * **Option A (0.10%):** This value is too low; while the risk is minimal, it is clinically recognized as 1% over a long-term follow-up. * **Option B (2%):** While close, 1% is the standard textbook figure for simple hyperplasia without atypia. * **Option D (10%):** This figure is more representative of **Complex Hyperplasia without atypia** (which has a ~3% risk) or approaching the risk of **Simple Hyperplasia with atypia** (~8-10%). **3. Clinical Pearls & High-Yield Facts:** To master this topic for the exam, remember the **"1, 3, 8, 29" rule** for progression to cancer: * **Simple Hyperplasia (without atypia):** 1% risk. * **Complex Hyperplasia (without atypia):** 3% risk. * **Simple Hyperplasia with atypia:** 8% risk. * **Complex Hyperplasia with atypia:** 29% risk (often rounded to 30%). **Management Tip:** For hyperplasia without atypia, the treatment of choice is Progestogens (Medroxyprogesterone acetate). For hyperplasia with atypia (especially in postmenopausal women), the treatment of choice is Total Hysterectomy due to the high risk of coexisting or future malignancy.

Question 644: A 38-year-old woman with a history of multiple sexual partners is most at risk for which of the following?

A. Bladder carcinoma
B. Cervical carcinoma (Correct Answer)
C. Endometrial carcinoma
D. Ovarian carcinoma

Explanation: **Explanation:** The correct answer is **Cervical Carcinoma**. **1. Why Cervical Carcinoma is Correct:** Cervical cancer is strongly associated with persistent infection by high-risk strains of **Human Papillomavirus (HPV)**, most commonly types 16 and 18. HPV is a sexually transmitted infection. Risk factors that increase the likelihood of HPV exposure and persistence include **multiple sexual partners**, early age at first intercourse, a high-risk male partner, and smoking. In this clinical scenario, the patient’s sexual history is the primary driver for cervical malignancy. **2. Why Other Options are Incorrect:** * **Bladder Carcinoma:** The primary risk factors are cigarette smoking and occupational exposure to aromatic amines (e.g., aniline dyes). It is not linked to sexual behavior. * **Endometrial Carcinoma:** This is primarily driven by **unopposed estrogen**. Risk factors include obesity, nulliparity, early menarche, late menopause, and PCOS. Sexual history is not a risk factor. * **Ovarian Carcinoma:** Risk is associated with "incessant ovulation." Factors like nulliparity and family history (BRCA mutations) increase risk, while combined oral contraceptives (COCs) and multiparity are protective. **3. NEET-PG High-Yield Pearls:** * **HPV 16** is the most common cause of Squamous Cell Carcinoma (SCC) of the cervix. * **HPV 18** is more frequently associated with Adenocarcinoma of the cervix. * The **Transformation Zone (Squamocolumnar Junction)** is the most common site for cervical neoplastic changes. * **Screening:** PAP smear (cytology) and HPV DNA testing are the gold standards for early detection. * **Vaccination:** The ideal age for HPV vaccination is 9–14 years (before sexual debut).

Question 645: Krukenberg adenocarcinoma of the ovary can occur as a result of metastases from all except?

A. Stomach
B. Breast
C. Liver (Correct Answer)
D. Pancreas

Explanation: **Explanation:** A **Krukenberg tumor** is a metastatic signet-ring cell adenocarcinoma of the ovary. The primary characteristic of this tumor is the presence of mucin-secreting "signet-ring" cells within a cellular stroma derived from the ovarian medulla. **Why Liver is the correct answer:** While the liver is a common site for primary malignancies (HCC) and a frequent site for metastases *from* other organs, it is **not** a recognized primary source for Krukenberg tumors. Krukenberg tumors specifically originate from glandular (mucinous) epithelium of the gastrointestinal tract or breast. **Analysis of Incorrect Options:** * **Stomach (Option A):** This is the **most common** primary site (approx. 70%). Gastric adenocarcinoma spreads to the ovaries via retrograde lymphatic dissemination or transcoelomic shedding. * **Breast (Option B):** Lobular carcinoma of the breast is a well-documented primary source for Krukenberg tumors. * **Pancreas (Option D):** Along with the colon, appendix, and gallbladder, the pancreas is a recognized primary site for these metastatic lesions. **NEET-PG High-Yield Pearls:** * **Most Common Primary:** Stomach (specifically the pylorus). * **Microscopic Hallmark:** Signet-ring cells (nucleus pushed to the periphery by a large mucin vacuole). * **Laterality:** Usually **bilateral** (80% of cases), which helps distinguish it from primary ovarian cancer. * **Route of Spread:** Historically thought to be transcoelomic (seeding), but **retrograde lymphatic spread** is now considered the most likely pathway. * **Stain:** PAS (Periodic Acid-Schiff) and Mucicarmine stains are positive for mucin.

Question 646: Intrauterine exposure of diethylstilbestrol is associated with which of the following conditions?

A. Squamous cell carcinoma of the cervix
B. Adenocarcinoma of the endometrium
C. Clear cell adenocarcinoma of the vagina (Correct Answer)
D. Sarcoma of the uterus

Explanation: **Explanation:** **Diethylstilbestrol (DES)** is a synthetic non-steroidal estrogen that was historically prescribed to pregnant women to prevent miscarriages. However, it is now a classic medical example of **transplacental carcinogenesis**. **Why Option C is Correct:** Female fetuses exposed to DES in utero (often called "DES daughters") have a significantly increased risk of developing **Clear cell adenocarcinoma (CCAC) of the vagina and cervix**. The peak incidence occurs in the late teens and early twenties. The underlying mechanism involves the failure of the normal transformation of the Müllerian duct columnar epithelium into squamous epithelium, leading to **vaginal adenosis** (the presence of glandular tissue in the vagina), which serves as a precursor to CCAC. **Why Other Options are Incorrect:** * **Option A:** Squamous cell carcinoma of the cervix is primarily associated with high-risk Human Papillomavirus (HPV) infection (Types 16, 18), not DES exposure. * **Option B:** Endometrial adenocarcinoma is linked to prolonged unopposed estrogen exposure (obesity, PCOS, HRT), but not specifically to in utero DES exposure. * **Option D:** Uterine sarcomas are rare mesenchymal tumors and do not have a documented causal link with fetal DES exposure. **High-Yield Clinical Pearls for NEET-PG:** * **Structural Abnormalities:** DES exposure is also associated with a **T-shaped uterine cavity**, cervical collars, and cockscomb cervix. * **Vaginal Adenosis:** This is the most common benign finding in DES daughters (found in >30%). * **Male Offspring:** DES exposure in males is linked to epididymal cysts, cryptorchidism, and microphallus. * **Diagnosis:** CCAC is often found on the **upper third of the anterior vaginal wall**.

Question 647: A woman presents with a 12-week pregnancy complaining of excessive vomiting and mild vaginal bleeding for two weeks. Her fundal height measures 16 weeks, and the cervical os is closed. An ultrasound reveals a snowstorm appearance in part of the uterus along with a fetus measuring 10 weeks crown-rump length. Fetal heart activity is absent. What is the best management option?

A. Medical termination with vaginal misoprostol
B. Medical termination with an oxytocin infusion
C. Suction evacuation (Correct Answer)
D. Total abdominal hysterectomy

Explanation: ### Explanation The clinical presentation of a uterus larger than dates, excessive vomiting (hyperemesis), vaginal bleeding, and the characteristic **"snowstorm appearance"** on ultrasound alongside a fetus suggests a **Partial Hydatidiform Mole**. In this case, the fetus is non-viable (absent heart activity), and the diagnosis is likely a triploid partial mole. **1. Why Suction Evacuation is the Correct Answer:** Suction evacuation is the **gold standard** and treatment of choice for all types of molar pregnancies (complete or partial), regardless of uterine size. It is preferred because it allows for rapid emptying of the uterus while minimizing the risk of uterine perforation and reducing the risk of persistent gestational trophoblastic neoplasia (GTN). **2. Why Other Options are Incorrect:** * **Medical Termination (Misoprostol/Oxytocin):** These are generally avoided in molar pregnancies. They increase the risk of **trophoblastic embolization** to the lungs and are often ineffective due to the high volume of molar tissue, leading to incomplete evacuation and increased hemorrhage. * **Total Abdominal Hysterectomy:** This is an over-treatment for a 12-week pregnancy. It is only considered in older patients (usually >40 years) who have completed their family and wish for permanent sterilization, as it reduces the risk of post-molar GTN but does not eliminate it. **3. High-Yield Clinical Pearls for NEET-PG:** * **Partial vs. Complete Mole:** Partial moles are usually **triploid (69, XXX or 69, XXY)** and contain fetal parts. Complete moles are **diploid (46, XX)**, have no fetal parts, and have a higher risk of malignancy (15-20% vs. <5% for partial). * **Snowstorm Appearance:** This is the classic USG finding representing multiple hydropic villi. * **Follow-up:** Post-evacuation, patients must be monitored with **weekly serum β-hCG levels** until three consecutive negative results are obtained, then monthly for 6 months to screen for GTN. * **Theca Lutein Cysts:** Often associated with complete moles due to very high β-hCG levels; these usually regress spontaneously after evacuation.

Question 648: Which of the following is the most common form of persistent trophoblastic disease that follows a non-molar pregnancy?

A. Choriocarcinoma (Correct Answer)
B. Invasive mole
C. Placental site trophoblastic tumor
D. Partial mole

Explanation: **Explanation:** The correct answer is **Choriocarcinoma**. Gestational Trophoblastic Neoplasia (GTN) can follow any type of pregnancy. However, the distribution of histological types varies significantly based on the preceding pregnancy: 1. **Choriocarcinoma:** This is the most common form of GTN following a **non-molar pregnancy** (normal term delivery, abortion, or ectopic pregnancy). Approximately 50% of choriocarcinomas arise from hydatidiform moles, 25% from abortions, and 25% from term pregnancies. It is characterized by the absence of chorionic villi and early hematogenous spread, most commonly to the lungs. 2. **Invasive Mole:** This almost exclusively follows a **hydatidiform mole** (usually complete). It is characterized by the presence of chorionic villi within the myometrium. It does not occur after a term pregnancy or abortion. 3. **Placental Site Trophoblastic Tumor (PSTT):** This is a rare variant that arises from intermediate trophoblasts. While it can follow any pregnancy, it is much less common than choriocarcinoma. 4. **Partial Mole:** This is a type of hydatidiform mole (usually triploid 69,XXX or 69,XXY) and is a *precursor* to persistent disease, not the form of the persistent disease itself. **NEET-PG High-Yield Pearls:** * **Most common site of metastasis:** Lungs (presents as "cannonball" shadows on X-ray). * **Tumor Marker:** Beta-hCG is the sensitive marker for diagnosis and monitoring. * **PSTT characteristic:** Produces low levels of hCG but high levels of Human Placental Lactogen (hPL); it is relatively chemoresistant and often requires surgery. * **Rule of Thumb:** If GTN follows a term pregnancy, it is **always** a choriocarcinoma.

Question 649: A 38-year-old female has a Pap smear suggestive of HSIL. Colposcopy-directed biopsy can reveal all of the following, EXCEPT:

A. Cervical intraepithelial neoplasia grade 1 (CIN-1) (Correct Answer)
B. Cervical intraepithelial neoplasia grade 2 (CIN-2)
C. Cervical intraepithelial neoplasia grade 3 (CIN-3)
D. Carcinoma in situ

Explanation: ### Explanation The core concept here is the correlation between **Cytology** (Pap smear) and **Histology** (Biopsy). **Why Option A is the correct answer:** According to the Bethesda System, **HSIL (High-grade Squamous Intraepithelial Lesion)** on a Pap smear is a cytological category that encompasses high-grade changes. Histologically, HSIL corresponds to **CIN-2, CIN-3, and Carcinoma in situ (CIS)**. **CIN-1** is histologically classified as **LSIL (Low-grade Squamous Intraepithelial Lesion)**. While a biopsy might occasionally show a lower grade than the Pap smear due to sampling error, in the context of standardized medical examinations, HSIL is defined by the presence of CIN-2 or worse. Therefore, CIN-1 is the "odd one out" as it represents a low-grade lesion. **Analysis of Incorrect Options:** * **B & C (CIN-2 and CIN-3):** These are the classic histological findings for a patient with HSIL cytology. CIN-2 (moderate dysplasia) and CIN-3 (severe dysplasia) involve the upper two-thirds or the full thickness of the epithelium, respectively. * **D (Carcinoma in situ):** This is the most advanced stage of CIN-3 where the full thickness of the epithelium is involved but the basement membrane remains intact. It is included under the umbrella of HSIL. **High-Yield Clinical Pearls for NEET-PG:** 1. **Bethesda Correlation:** * LSIL (Cytology) $\approx$ CIN-1 (Histology). * HSIL (Cytology) $\approx$ CIN-2, CIN-3, CIS (Histology). 2. **Management:** Any HSIL on Pap smear requires mandatory **Colposcopy** and directed biopsy. In some guidelines (ASCCP), "See and Treat" (LEEP) may be considered for HSIL in non-pregnant women over 25. 3. **Hallmark of CIN:** The presence of **koilocytes** (perinuclear halo with wrinkled nuclei) is characteristic of HPV infection, typically seen in LSIL/CIN-1.

Question 650: A 23-year-old female presents with pelvic pain and is found to have a 3 cm ovarian mass on the left ovary. Grossly, the mass consists of multiple cystic spaces. Histologically, these cysts are lined by tall columnar epithelium, with some of the cells being ciliated. What is your diagnosis of this ovarian tumor, which histologically recapitulates the histology of the fallopian tubes?

A. Serous tumor (Correct Answer)
B. Mucinous tumor
C. Endometrioid tumor
D. Clear cell tumor

Explanation: **Explanation:** The correct diagnosis is a **Serous tumor**. The key to this question lies in the histological description: "tall columnar epithelium, with some of the cells being ciliated." In gynecologic pathology, ovarian surface epithelial tumors are classified based on the type of adult female reproductive tract tissue they "recapitulate" or mimic. 1. **Serous tumors** mimic the lining of the **fallopian tube** (endosalpinx). They are characterized by tall columnar ciliated cells. 2. **Mucinous tumors** mimic the **endocervix** or intestinal epithelium, characterized by cells containing apical mucin. 3. **Endometrioid tumors** mimic the **endometrium** (uterine lining). 4. **Clear cell tumors** are thought to mimic the **gestational endometrium** (decidua) and are often associated with endometriosis. **Why the other options are incorrect:** * **Mucinous tumor:** These would show non-ciliated cells with abundant intracellular mucin (resembling endocervical glands). * **Endometrioid tumor:** These typically form tubular glands resembling the lining of the uterus, often associated with endometriosis. * **Clear cell tumor:** These are characterized by "hobnail" cells and clear cytoplasm due to glycogen accumulation. **High-Yield NEET-PG Pearls:** * **Serous Cystadenoma** is the most common benign epithelial ovarian tumor. * **Psammoma bodies** (concentric calcifications) are a classic histological hallmark of serous tumors (especially papillary serous cystadenocarcinoma). * **Bilateralism:** Serous tumors are the most common ovarian tumors to be bilateral (approx. 25% of benign and 65% of malignant cases). * **Tumor Marker:** CA-125 is the most common marker used for monitoring epithelial ovarian tumors, particularly the serous subtype.

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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