Gynecologic Oncology — MCQs
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What is the point of distinction between a partial mole and a complete mole?
What is the most common side effect of cryotherapy for carcinoma cervix in situ?
A 23-year-old woman consults an obstetrician because of vaginal bleeding in what she considers to be the fifth month of pregnancy. Examination reveals the uterus to be enlarged to the size of a 7-month pregnancy. Intravaginal ultrasound fails to detect a fetal heartbeat and instead shows a "snowstorm pattern." HCG is markedly elevated. These findings are strongly suggestive of:
Hydatidiform mole is associated with which of the following?
Cervical cone biopsy in a case of carcinoma cervix causes all complications except:
Prophylactic chemotherapy is indicated after evacuation of hydatidiform mole in all cases EXCEPT:
In carcinoma of the ovary, which stage involves inguinal lymph nodes?
Which one of the following tumors involving the female genital tract has the worst prognosis?
Brachytherapy is used in which of the following conditions?
Call Exner bodies are characteristic microscopic findings in which of the following tumors?
Gynecologic Oncology Indian Medical PG Practice Questions and MCQs
Question 661: What is the point of distinction between a partial mole and a complete mole?
- A. Partial mole shows trophoblastic proliferation with absent villi.
- B. Typical of partial mole is cellular atypia.
- C. Partial mole is more prone to malignant transformation.
- D. Partial mole is triploid. (Correct Answer)
Explanation: **Explanation:** The fundamental distinction between a partial and a complete hydatidiform mole lies in their genetic makeup and histopathological features. **1. Why Option D is Correct:** A **Partial Mole** is typically **triploid (69,XXX; 69,XXY; or 69,XYY)**. It occurs when a normal haploid oocyte is fertilized by two sperm (dispermy) or one sperm that duplicates its chromosomes. In contrast, a **Complete Mole** is **diploid (46,XX or 46,XY)**, usually formed by a single sperm fertilizing an "empty" egg (anucleated) and then duplicating its own DNA (androgenetic). **2. Why the Other Options are Incorrect:** * **Option A:** Both partial and complete moles exhibit **villous** structures. However, in a partial mole, villous edema is focal and some normal-appearing villi are present, whereas in a complete mole, there is generalized hydropic swelling of all villi ("bunch of grapes" appearance). * **Option B:** Cellular atypia and circumferential trophoblastic proliferation are hallmarks of a **Complete Mole**. In partial moles, trophoblastic proliferation is focal and mild. * **Option C:** **Complete moles** are significantly more prone to malignant transformation (Gestational Trophoblastic Neoplasia) in about 15–20% of cases. Partial moles carry a much lower risk (<5%). **High-Yield Clinical Pearls for NEET-PG:** * **Fetal Parts:** Present in Partial Moles; absent in Complete Moles. * **p57 Expression:** Partial moles are **p57 positive** (maternal DNA present); Complete moles are **p57 negative** (maternal DNA absent). * **hCG Levels:** Markedly elevated in Complete Moles; only mildly elevated in Partial Moles. * **Theca Lutein Cysts:** Common in Complete Moles; rare in Partial Moles.
Question 662: What is the most common side effect of cryotherapy for carcinoma cervix in situ?
- A. Hemorrhage
- B. Persistent watery discharge (Correct Answer)
- C. Cervical stenosis
- D. Ulceration
Explanation: **Explanation:** Cryotherapy is an ablative procedure used for Cervical Intraepithelial Neoplasia (CIN) that involves freezing the cervical tissue (usually using nitrous oxide or carbon dioxide) to induce cellular necrosis. **Why "Persistent Watery Discharge" is correct:** The primary mechanism of cryotherapy involves the destruction of the cervical epithelium and the underlying stroma. As the frozen, necrotic tissue sloughs off and the underlying basement membrane heals, there is a significant inflammatory response. This leads to a **profuse, thin, watery vaginal discharge** (hydrorrhea) that typically lasts for 2 to 4 weeks. This is the most frequent and expected side effect, and patients must be counseled about it pre-operatively to avoid unnecessary anxiety. **Analysis of Incorrect Options:** * **A. Hemorrhage:** Unlike LEEP or cold knife conization, cryotherapy is relatively bloodless because the freezing process causes vasoconstriction and minimal vascular disruption. * **C. Cervical Stenosis:** This is a rare complication of cryotherapy. It is much more common after excisional procedures (like Conization) where deep tissue is removed. * **D. Ulceration:** While the procedure creates a temporary necrotic area, "ulceration" is a part of the healing process rather than a primary clinical side effect reported by the patient. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Cryotherapy uses the "Freeze-Thaw-Freeze" technique. * **Depth of Necrosis:** It typically achieves a depth of 4–5 mm. * **Criteria for Cryotherapy:** The lesion must be visible, involve no more than 2 quadrants, not extend into the endocervix, and there must be no suspicion of invasive cancer. * **Failure Rate:** It has a higher failure rate for larger lesions (>20 mm) compared to LEEP.
Question 663: A 23-year-old woman consults an obstetrician because of vaginal bleeding in what she considers to be the fifth month of pregnancy. Examination reveals the uterus to be enlarged to the size of a 7-month pregnancy. Intravaginal ultrasound fails to detect a fetal heartbeat and instead shows a "snowstorm pattern." HCG is markedly elevated. These findings are strongly suggestive of:
- A. Preeclampsia.
- B. Eclampsia.
- C. Ectopic pregnancy.
- D. Hydatidiform mole. (Correct Answer)
Explanation: ### Explanation **Correct Option: D. Hydatidiform mole** The clinical presentation is classic for a **Molar Pregnancy (Gestational Trophoblastic Disease)**. The key diagnostic features provided are: 1. **Size-Date Discrepancy:** The uterus is significantly larger (7 months) than the period of amenorrhea (5 months) due to rapid trophoblastic proliferation and accumulated blood. 2. **"Snowstorm Pattern" on Ultrasound:** This pathognomonic finding represents multiple hydropic villi (vesicles) and intrauterine hemorrhage, with the absence of a fetus (in complete mole). 3. **Markedly Elevated hCG:** Trophoblastic hyperplasia leads to hCG levels far exceeding those of a normal singleton pregnancy (often >100,000 mIU/mL). 4. **Vaginal Bleeding:** Often described as "prune juice" discharge as the vesicles detach. **Why Incorrect Options are Wrong:** * **A & B (Preeclampsia/Eclampsia):** While preeclampsia occurring *before 20 weeks* is a known complication of a molar pregnancy, these options do not explain the "snowstorm" ultrasound or the uterine size discrepancy. * **C (Ectopic Pregnancy):** This typically presents with a *smaller* than expected uterus, lower than normal hCG doubling times, and an empty uterine cavity on ultrasound, rather than a snowstorm mass. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (presents as "cannonball" lesions on X-ray). * **Theca Lutein Cysts:** Often seen bilaterally on ovaries due to extreme hCG stimulation. * **Management:** Suction Evacuation is the treatment of choice, regardless of uterine size. * **Follow-up:** Weekly hCG monitoring until three consecutive negative results to rule out Persistent Gestational Trophoblastic Neoplasia (GTN).
Question 664: Hydatidiform mole is associated with which of the following?
- A. Follicular ovarian cysts
- B. Theca lutein cysts (Correct Answer)
- C. Ovarian carcinoma
- D. Ovarian atrophy
Explanation: **Explanation:** **Theca lutein cysts** are the classic ovarian finding associated with gestational trophoblastic disease (GTD), such as hydatidiform moles. **Why the correct answer is right:** Hydatidiform moles produce pathologically high levels of **human chorionic gonadotropin (hCG)**. Because the alpha-subunit of hCG is structurally identical to that of Luteinizing Hormone (LH), high concentrations of hCG cross-react with LH receptors on the ovarian theca cells. This leads to massive luteinization and follicular overstimulation, resulting in bilateral, multicystic ovarian enlargement known as theca lutein cysts. These cysts are typically benign and regress spontaneously once the mole is evacuated and hCG levels drop. **Why the incorrect options are wrong:** * **A. Follicular ovarian cysts:** These are common physiological cysts related to the normal menstrual cycle and are not specifically triggered by the hyperstimulation seen in molar pregnancies. * **C. Ovarian carcinoma:** While gestational trophoblastic neoplasia (like choriocarcinoma) can occur, a mole does not directly cause primary ovarian cancer. Theca lutein cysts are benign. * **D. Ovarian atrophy:** Molar pregnancy causes ovarian *hypertrophy* (enlargement) due to hormonal overstimulation, not atrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence:** Theca lutein cysts occur in approximately 25–30% of patients with a complete hydatidiform mole. * **Appearance on Ultrasound:** Described as a **"spoke-wheel"** appearance due to multiple large, thin-walled septations. * **Complications:** Although they usually regress, they can predispose the patient to **ovarian torsion** or rupture due to their large size. * **Management:** Conservative management is preferred; they should not be surgically removed as they resolve following the treatment of the mole.
Question 665: Cervical cone biopsy in a case of carcinoma cervix causes all complications except:
- A. Bleeding
- B. Cervical stenosis
- C. Infection
- D. Spread of malignancy (Correct Answer)
Explanation: **Explanation:** Cervical cone biopsy (conization) is a diagnostic and sometimes therapeutic procedure used to manage cervical intraepithelial neoplasia (CIN) and early-stage cervical cancer. **Why "Spread of Malignancy" is the correct answer:** Unlike some other cancers where biopsy might risk "seeding" or track metastasis, a cervical cone biopsy does not cause the spread of malignancy. In fact, conization is the gold standard for determining the exact depth of invasion in microinvasive carcinoma (Stage IA1). It allows for the definitive assessment of margins and lymphovascular space invasion (LVSI). It is a localized surgical excision and does not promote systemic or regional dissemination of cancer cells. **Analysis of Incorrect Options:** * **Bleeding:** This is the most common **immediate** complication. The cervix is highly vascular, and the descending branches of the uterine artery can cause significant intraoperative or delayed (secondary) hemorrhage. * **Cervical Stenosis:** This is a **late** complication. Extensive removal of the endocervical canal or excessive cauterization can lead to scarring and narrowing of the cervical os, potentially causing hematometra or infertility. * **Infection:** As with any surgical procedure involving the vaginal flora, postoperative cervicitis or pelvic inflammatory disease (PID) can occur. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Performed when there is a discrepancy between cytology and colposcopy, if the squamocolumnar junction (SCJ) is not fully visible, or to rule out invasion. * **Obstetric Complications:** Cone biopsy increases the risk of **cervical insufficiency** and preterm pre-labor rupture of membranes (PPROM) in future pregnancies. * **Techniques:** Cold knife conization (CKC) is preferred for histopathological margin assessment, while LEEP (Loop Electrosurgical Excision Procedure) is common for CIN.
Question 666: Prophylactic chemotherapy is indicated after evacuation of hydatidiform mole in all cases EXCEPT:
- A. Initial level of urine hCG is 40,000 IU/L after 6 weeks of evacuation
- B. Increase in hCG titre to 24,000 IU/L after 10 weeks of evacuation
- C. Presence of metastasis
- D. Nulliparous patient (Correct Answer)
Explanation: **Explanation:** The management of Hydatidiform Mole (HM) primarily involves suction evacuation followed by serial hCG monitoring. **Prophylactic chemotherapy** is not routinely recommended for all patients because 80% of cases resolve spontaneously, and chemotherapy carries risks of toxicity and drug resistance. **Why "Nulliparous patient" is the correct answer:** Parity (being nulliparous or multiparous) is not a clinical indicator for chemotherapy. The decision to initiate treatment is based on the risk of malignant transformation (Gestational Trophoblastic Neoplasia - GTN), not the patient's reproductive history. In fact, for older patients who have completed their family, a prophylactic hysterectomy may be considered, but nulliparity itself is never an indication for chemotherapy. **Analysis of Incorrect Options (Indications for Chemotherapy):** * **Options A & B (hCG levels):** According to FIGO criteria, chemotherapy is indicated if hCG levels plateau (stay within ±10% over 3 weeks) or rise (increase >10% over 2 consecutive weeks). A high titre of 40,000 IU/L at 6 weeks or a significant rise to 24,000 IU/L at 10 weeks suggests persistent disease or malignant transformation into Choriocarcinoma or Invasive Mole. * **Option C (Metastasis):** The presence of any clinical or radiological evidence of metastasis (commonly to lungs or vagina) automatically classifies the condition as GTN, requiring immediate chemotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Scoring:** Used for GTN to decide between single-agent (Methotrexate) or multi-agent (EMA-CO) chemotherapy. * **Follow-up Protocol:** hCG is monitored weekly until three consecutive negatives (<5 mIU/mL), then monthly for 6 months. * **Contraception:** Essential during the follow-up period (OCPs are preferred) to avoid confusing a new pregnancy with rising hCG from a relapse. * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%).
Question 667: In carcinoma of the ovary, which stage involves inguinal lymph nodes?
- A. Stage II
- B. Stage III a
- C. Stage IIIc
- D. Stage IVb (Correct Answer)
Explanation: **Explanation:** In the FIGO staging system for ovarian cancer (updated 2014), the involvement of **inguinal lymph nodes** is classified as **Stage IVB**. The underlying medical concept is based on the anatomical location of these nodes. Inguinal nodes are considered **extra-abdominal (distant) lymph nodes**. While retroperitoneal nodes (pelvic and para-aortic) are regional to the ovary, any spread to nodes outside the abdominal cavity—such as inguinal, supraclavicular, or axillary nodes—signifies distant metastatic disease (Stage IV). **Analysis of Options:** * **Stage II:** Disease is limited to pelvic extension (below the pelvic brim) or primary peritoneal cancer. No lymph node involvement is included in Stage II. * **Stage IIIa:** Involves microscopic peritoneal metastasis beyond the pelvis OR metastasis to **retroperitoneal** (pelvic/para-aortic) lymph nodes only (Stage IIIa1). * **Stage IIIc:** Involves macroscopic peritoneal metastasis >2 cm beyond the pelvis. While it may include retroperitoneal nodes, it does not include extra-abdominal nodes. * **Stage IVb (Correct):** This stage represents distant metastasis, which includes parenchymal metastases (liver/spleen) and involvement of **extra-abdominal organs**, including **inguinal lymph nodes** and skin. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IVa:** Specifically refers to **pleural effusion** with positive cytology. * **Most common route of spread:** Transcoelomic (exfoliation of cells into the peritoneal cavity). * **Lymphatic drainage:** The primary drainage of the ovary is via the infundibulopelvic ligament directly to the **para-aortic nodes** at the level of the renal hilum. * **Sister Mary Joseph Nodule:** Metastasis to the umbilicus, also classified as Stage IVB.
Question 668: Which one of the following tumors involving the female genital tract has the worst prognosis?
- A. Dysgerminoma in a 35-year-old
- B. Uterine choriocarcinoma in a 25-year-old with a recent history of molar pregnancy
- C. Granulosa cell tumor in a 40-year-old
- D. Serous cystadenocarcinoma of the ovary in a 45-year-old (Correct Answer)
Explanation: **Explanation:** The prognosis of gynecologic tumors depends on their biological behavior, chemosensitivity, and stage at presentation. **Serous cystadenocarcinoma** is the most common type of epithelial ovarian cancer (EOC). It has the worst prognosis among the options because it is typically diagnosed at an advanced stage (Stage III or IV) due to its "silent" progression and rapid intraperitoneal spread. Unlike germ cell tumors, it has a high recurrence rate and lower long-term survival. **Analysis of Options:** * **Dysgerminoma (Option A):** These are highly radiosensitive and chemosensitive germ cell tumors. Even in advanced stages, the cure rate is excellent (>90%), making it one of the most treatable ovarian malignancies. * **Uterine Choriocarcinoma (Option B):** While highly aggressive and prone to early hematogenous metastasis (to lungs), gestational choriocarcinoma is exquisitely sensitive to chemotherapy (e.g., Methotrexate). It is considered a "curable" cancer even in the presence of metastasis. * **Granulosa Cell Tumor (Option C):** These are "low-grade" sex cord-stromal tumors. They have an indolent course, are usually diagnosed at Stage I, and have a very high 10-year survival rate, though they require long-term follow-up due to late recurrences. **Clinical Pearls for NEET-PG:** * **Most common ovarian malignancy:** Serous cystadenocarcinoma. * **Tumor Marker for Serous Ca:** CA-125 (used for monitoring, not screening). * **Psammoma bodies:** Characteristic histological finding in Serous cystadenocarcinoma. * **Call-Exner bodies:** Pathognomonic for Granulosa cell tumors (Inhibin is the marker). * **LDH:** The characteristic marker for Dysgerminoma.
Question 669: Brachytherapy is used in which of the following conditions?
- A. Stage Ib Ca cervix (Correct Answer)
- B. Ovarian Ca
- C. Stage IV Ca vagina
- D. Stage II fallopian tube Ca
Explanation: **Explanation:** **1. Why Stage Ib Ca Cervix is Correct:** Brachytherapy (internal radiation) is a cornerstone in the management of cervical cancer. For **Stage Ib Ca Cervix**, the standard treatment is either a Radical Hysterectomy with pelvic lymphadenectomy or **Definitive Radiotherapy**. Radiotherapy for cervical cancer typically involves a combination of External Beam Radiation Therapy (EBRT) and **Brachytherapy**. Brachytherapy allows for the delivery of a high dose of radiation directly to the tumor (the cervix) while sparing adjacent critical organs like the bladder and rectum, utilizing the inverse square law. **2. Why the other options are incorrect:** * **Ovarian Ca:** The primary treatment is cytoreductive surgery followed by systemic chemotherapy (Paclitaxel + Carboplatin). Brachytherapy is not used because ovarian cancer tends to spread throughout the peritoneal cavity, requiring systemic rather than localized internal radiation. * **Stage IV Ca Vagina:** While brachytherapy is used in early-stage vaginal cancer, Stage IV involves distant metastasis or extension into the bladder/rectal mucosa. Treatment at this stage is usually palliative EBRT or chemotherapy; the disease is too extensive for localized brachytherapy to be effective as a primary modality. * **Stage II Fallopian Tube Ca:** Similar to ovarian cancer, fallopian tube cancers are managed with staging surgery and systemic chemotherapy due to their pattern of intraperitoneal spread. **Clinical Pearls for NEET-PG:** * **Manchester System:** Used in cervical brachytherapy to define **Point A** (2cm superior to the external os and 2cm lateral to the uterine canal) and **Point B** (3cm lateral to Point A). * **Most common isotope used:** Iridium-192 (High Dose Rate) or Cesium-137 (Low Dose Rate). * **Stockholm and Paris systems** are other historical methods of cervical brachytherapy application.
Question 670: Call Exner bodies are characteristic microscopic findings in which of the following tumors?
- A. Granulosa cell tumor (Correct Answer)
- B. Embryonal cell carcinoma
- C. Choriocarcinoma
- D. Androblastoma
Explanation: **Explanation:** **Call-Exner bodies** are the pathognomonic histological hallmark of **Granulosa Cell Tumors (GCT)**, specifically the adult type. These are small, fluid-filled spaces surrounded by granulosa cells arranged in a rosette-like pattern. The fluid within these spaces represents secreted basement membrane material and excess estrogenic precursors. **Analysis of Options:** * **A. Granulosa Cell Tumor (Correct):** These are sex cord-stromal tumors. Microscopically, they feature "coffee-bean" nuclei (due to longitudinal grooves) and Call-Exner bodies. Clinically, they are known for producing **Estrogen**, leading to precocious puberty in children or postmenopausal bleeding in adults. * **B. Embryonal Cell Carcinoma:** A highly aggressive germ cell tumor characterized by primitive cells arranged in sheets, glands, or papillae. It typically produces **Alpha-fetoprotein (AFP) and hCG**, but lacks Call-Exner bodies. * **C. Choriocarcinoma:** A gestational trophoblastic neoplasm characterized by the proliferation of cytotrophoblasts and syncytiotrophoblasts with central hemorrhage and necrosis. Its hallmark marker is markedly elevated **beta-hCG**. * **D. Androblastoma (Sertoli-Leydig Cell Tumor):** These tumors typically produce androgens, leading to virilization. Histology shows tubules lined by Sertoli cells and clusters of Leydig cells containing **Reinke crystals**, not Call-Exner bodies. **High-Yield NEET-PG Pearls:** * **Tumor Marker for GCT:** Inhibin (specifically Inhibin B) is used for diagnosis and monitoring recurrence. * **Microscopic Key:** "Coffee-bean" nuclei + Call-Exner bodies = Granulosa Cell Tumor. * **Clinical Association:** GCT is associated with endometrial hyperplasia or carcinoma due to chronic estrogen exposure. * **Schiller-Duval Bodies:** Characteristic of Yolk Sac Tumors (Endodermal Sinus Tumors).
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
Practice Questions
Principles of Gynecologic Oncology Surgery
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Radiation Therapy in Gynecologic Malignancies
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Chemotherapy in Gynecologic Oncology
Practice Questions
Palliative Care in Gynecologic Oncology
Practice Questions
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