Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 671: In colposcopy, which of the following is NOT visualized?

A. Upper two-thirds of the endocervix (Correct Answer)
B. Cervical carcinoma in situ
C. Cervical polyp
D. Cervical dysplasia

Explanation: **Explanation:** The correct answer is **A. Upper two-thirds of the endocervix**. Colposcopy is a diagnostic procedure used to visualize the cervix, vagina, and vulva under magnification. Its primary limitation is that it is a **surface-viewing tool**. While it can visualize the ectocervix and the lower part of the endocervical canal (depending on the visibility of the Transformation Zone), it cannot see deep into the endocervical canal. The upper two-thirds of the endocervix are anatomically "blind" to the colposcope; lesions located here require an endocervical curettage (ECC) or conization for evaluation. **Analysis of Options:** * **Cervical carcinoma in situ (B) and Cervical dysplasia (D):** These are the primary indications for colposcopy. The procedure identifies abnormal vascular patterns (punctations, mosaicism) and acetowhite epithelium associated with these conditions, provided they are located on the visible ectocervix or the distal endocervix. * **Cervical polyp (C):** Since polyps usually protrude from the external os or are attached to the visible portion of the cervix, they are easily visualized during colposcopy. **High-Yield Clinical Pearls for NEET-PG:** * **Satisfactory Colposcopy:** Defined as the ability to visualize the **entire Squamocolumnar Junction (SCJ)** and the margins of any visible lesion. * **Unsatisfactory Colposcopy:** Occurs if the SCJ is recessed into the endocervical canal (common in postmenopausal women). In such cases, the "upper" limits of the lesion cannot be seen. * **Reagents used:** 3–5% Acetic acid (highlights acetowhite areas) and Lugol’s Iodine (Schiller’s test; mature squamous cells stain mahogany brown, while dysplastic cells remain unstained/yellow). * **Indications for ECC:** Performed during colposcopy if the SCJ is not fully visualized or if the lesion extends into the canal.

Question 672: Which of the following is NOT a common recurrence or metastatic site of malignancy following pelvic surgery?

A. Carcinoma of the cervix - Lateral pelvic wall and central pelvis
B. Carcinoma of the ovary - Lung (Correct Answer)
C. Chorionepithelioma - Suburethral anterior vaginal wall
D. Carcinoma of the body of the uterus - Vault of the vagina

Explanation: **Explanation:** The correct answer is **B (Carcinoma of the ovary - Lung)** because epithelial ovarian cancer primarily spreads via **exfoliation and intraperitoneal seeding**. The most common site of metastasis/recurrence is the **peritoneum and omentum** (forming an "omental cake"). While hematogenous spread to the lungs can occur in advanced Stage IV disease, it is not considered a "common" or characteristic primary recurrence site compared to the other options listed. **Analysis of Incorrect Options:** * **A. Carcinoma of the cervix:** Recurrence typically occurs locally in the **central pelvis** (vaginal vault/stump) or along the **lateral pelvic wall**, often leading to ureteral obstruction and uremia (the most common cause of death). * **C. Chorionepithelioma (Choriocarcinoma):** This is a highly vascular tumor with a predilection for hematogenous spread. The **vagina** (specifically the suburethral anterior wall) is a classic site for "blue-domed" metastatic nodules. * **D. Carcinoma of the body of the uterus:** Following a total hysterectomy for endometrial cancer, the **vaginal vault** is the most frequent site of isolated local recurrence. **NEET-PG High-Yield Pearls:** * **Choriocarcinoma:** Most common site of metastasis is the **Lung** (80%), followed by the **Vagina** (30%). * **Cervical Cancer:** Spreads primarily by direct extension and lymphatics. The "Triad of Death" in advanced cases includes uremia, infection, and hemorrhage. * **Ovarian Cancer:** The "Seed and Soil" hypothesis applies here; cancer cells "wash" through the peritoneal fluid and implant on the diaphragm and paracolic gutters.

Question 673: What is the treatment for a patient with a 20-week size uterus and a vesicular mole?

A. Induction of labor
B. Methotrexate
C. Hysterotomy
D. Suction evacuation (Correct Answer)

Explanation: **Explanation:** The gold standard treatment for a Hydatidiform Mole (molar pregnancy), regardless of the uterine size, is **Suction Evacuation**. **1. Why Suction Evacuation is Correct:** In a vesicular mole, the uterine cavity is filled with friable, hydropic villi. Suction evacuation is the preferred method because it is rapid, effective, and associated with the lowest risk of uterine perforation and trophoblastic embolization. Even in a 20-week size uterus, the tissue is soft and easily aspirated. It is typically performed using a large-bore cannula (10–14 mm) under oxytocin cover to prevent hemorrhage and ensure uterine contraction. **2. Why Other Options are Incorrect:** * **Induction of Labor (A):** Medical induction with prostaglandins or oxytocin is contraindicated. It increases the risk of uterine contractions forcing trophoblastic tissue into the systemic circulation, potentially leading to **trophoblastic embolism** and respiratory distress. * **Methotrexate (B):** This is a chemotherapeutic agent used for ectopic pregnancies or as part of the management for Gestational Trophoblastic Neoplasia (GTN). It is not the primary treatment for an initial molar evacuation. * **Hysterotomy (C):** Surgical opening of the uterus is avoided because it increases the risk of heavy bleeding, infection, and future uterine scarring. It also increases the risk of disseminating trophoblastic cells. **High-Yield NEET-PG Pearls:** * **Follow-up:** The most critical post-evacuation step is monitoring **weekly serum β-hCG levels** until three consecutive normal values are obtained, then monthly for 6 months. * **Contraception:** Patients must avoid pregnancy for at least 6 months post-normalization of hCG; **OCPs** are the preferred method. * **Theca Lutein Cysts:** These are often associated with moles due to high hCG; they usually regress spontaneously after evacuation and do not require surgery. * **Rh Isoimmunization:** Rh-negative mothers must receive **Anti-D prophylaxis** following evacuation.

Question 674: What is true about a hydatidiform mole?

A. Complete mole seen in humans only.
B. Trophoblastic proliferation. (Correct Answer)
C. Hydropic degeneration.
D. Villus pattern absent.

Explanation: ### Explanation **Correct Answer: B. Trophoblastic proliferation** Hydatidiform mole (Gestational Trophoblastic Disease) is characterized by two pathognomonic histological features: **trophoblastic proliferation** (involving both cytotrophoblast and syncytiotrophoblast) and **hydropic swelling of the chorionic villi**. While both are present, trophoblastic proliferation is the definitive diagnostic feature that distinguishes it from other conditions like hydropic abortus. **Analysis of Options:** * **A. Complete mole seen in humans only:** This is incorrect. While most common in humans, molar pregnancies have been documented in other mammals (e.g., macaques). * **C. Hydropic degeneration:** While hydropic change (swelling) occurs, "degeneration" is a misnomer. In a mole, the villi are living and proliferating; "hydropic degeneration" is a term more accurately used for a blighted ovum or missed abortion where the villi swell after fetal death. * **D. Villus pattern absent:** This is incorrect. The presence of **swollen chorionic villi** (resembling a "bunch of grapes") is the hallmark of a hydatidiform mole. The absence of villi is characteristic of Choriocarcinoma, not a mole. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Complete Mole is usually **46,XX** (diploid, paternal origin only/androgenetic). Partial Mole is usually **69,XXX/XXY** (triploid, maternal + paternal). * **Snowstorm Appearance:** Classic ultrasound finding due to multiple hydropic villi. * **Theca Lutein Cysts:** Often seen bilaterally due to extremely high hCG levels. * **Risk of Malignancy:** Higher in Complete Moles (15–20%) compared to Partial Moles (<5%). * **Management:** Suction evacuation is the treatment of choice; follow-up with weekly hCG levels until three consecutive negatives are achieved.

Question 675: Which of the following is a true statement regarding sarcoma botryoides?

A. Involvement of the vagina (Correct Answer)
B. Grape-like growth is seen
C. Common in the aged
D. Malignant

Explanation: **Explanation:** **Sarcoma botryoides** (Embryonal Rhabdomyosarcoma) is a highly malignant tumor derived from primitive mesenchymal cells. It is the most common vaginal tumor in infants and children. **Why Option A is correct:** The primary site of origin for sarcoma botryoides is the **vagina** in infants and young children (typically <5 years). In older children and adolescents, it more commonly involves the cervix or uterus. Since the question asks for a true statement regarding its characteristic presentation, vaginal involvement is a hallmark feature. **Analysis of Incorrect Options:** * **Option B (Grape-like growth is seen):** While the term "botryoides" literally means "resembling a bunch of grapes," this option is technically a **description of the morphology**, not a statement of clinical involvement or pathology. In many standardized exams (including NEET-PG), if "Involvement of the vagina" and "Grape-like growth" are both present, the anatomical site is often prioritized as the definitive clinical characteristic, though this can be a controversial "double-correct" scenario. * **Option C (Common in the aged):** This is incorrect. It is a tumor of **early childhood**, with 90% of cases occurring in children under the age of 5. * **Option D (Malignant):** While the tumor is indeed highly malignant, "Involvement of the vagina" is considered the more specific clinical identifier for this condition in the context of gynecologic oncology. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Feature:** Presence of the **Cambium layer** (a subepithelial layer of dense tumor cells) on histology. * **Clinical Presentation:** Usually presents as a "bloody vaginal discharge" or a "protruding mass from the introitus" in a toddler. * **Marker:** Desmin and Myogenin positive (indicates skeletal muscle origin). * **Treatment:** Multimodal therapy involving surgery (vagina-sparing whenever possible) followed by chemotherapy (VAC regimen: Vincristine, Actinomycin D, Cyclophosphamide).

Question 676: According to ABS guidelines, what is the recommended dose of radiation for point A in early and locally advanced cervical cancer during brachytherapy?

A. 70-75 Gy and 75-80 Gy
B. 75-75 Gy and 80-85 Gy
C. 80-85 Gy and 85-90 Gy (Correct Answer)
D. 85-90 Gy and 90-95 Gy

Explanation: **Explanation:** The management of cervical cancer involves a combination of External Beam Radiotherapy (EBRT) and Brachytherapy. The **American Brachytherapy Society (ABS)** guidelines provide specific cumulative dose recommendations (EBRT + Brachytherapy) to **Point A** to ensure local tumor control while minimizing toxicity to surrounding organs. 1. **Why Option C is Correct:** * For **Early-stage disease** (small volume tumors, e.g., IB1, IIA1), the recommended cumulative dose to Point A is **80–85 Gy**. * For **Locally Advanced disease** (bulky tumors, e.g., IB2, IIB–IVA), a higher dose of **85–90 Gy** is required to achieve optimal sterilization of the larger tumor volume. These doses are calculated as the biologically equivalent dose in 2 Gy fractions ($EQD_2$). 2. **Why Other Options are Incorrect:** * **Options A and B:** These doses (70–80 Gy) are generally considered suboptimal for definitive cure in cervical cancer and are associated with higher rates of local recurrence. * **Option D:** Doses exceeding 90–95 Gy significantly increase the risk of severe late-term complications, such as rectovaginal or vesicovaginal fistulas and radiation proctitis, without a proportional increase in survival benefit. **High-Yield Clinical Pearls for NEET-PG:** * **Point A Definition:** Located 2 cm superior to the external cervical os and 2 cm lateral to the uterine canal. It represents where the uterine artery crosses the ureter. * **Point B Definition:** Located 3 cm lateral to Point A (5 cm from the midline). It represents the pelvic side wall and lymph nodes. * **Manchester System:** The classic system used to define these points for dosage calculation. * **Standard Regimen:** Usually involves 45–50 Gy of EBRT followed by Brachytherapy (HDR or LDR) to reach the total target dose at Point A.

Question 677: A 55-year-old woman is diagnosed with Stage II-III cervical cancer, considered locally advanced. What is the recommended management?

A. Surgery plus chemotherapy
B. Radiotherapy plus chemotherapy (Correct Answer)
C. Chemotherapy alone
D. Radiotherapy plus HPV vaccine

Explanation: **Explanation:** The management of cervical cancer is primarily determined by the FIGO stage. For **Locally Advanced Cervical Cancer (LACC)**, which includes stages **IB3, IIA2, and Stage IIB to IVA**, the standard of care is **Concurrent Chemoradiotherapy (CCRT)**. 1. **Why Option B is Correct:** In locally advanced stages (like Stage II-III), the tumor has either reached a size >4cm or has spread beyond the cervix to the parametrium or pelvic wall. Surgery in these cases is associated with high morbidity and a high risk of positive margins. Clinical trials have proven that adding chemotherapy (specifically **Cisplatin**) to radiotherapy acts as a radiosensitizer, significantly improving overall survival and reducing recurrence compared to radiation alone. 2. **Why Options A, C, and D are Incorrect:** * **Option A:** Surgery (Radical Hysterectomy) is generally reserved for early-stage disease (Stage IA to IIA1). Combining surgery with post-operative radiation increases complications without improving survival in LACC. * **Option C:** Chemotherapy alone is not curative for cervical cancer; it is used for palliation in Stage IVB (metastatic disease). * **Option D:** The HPV vaccine is a preventive measure (primary prevention) and has no therapeutic role in treating established cervical cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Drug:** Cisplatin is the most common radiosensitizer used in CCRT. * **Stage IIB:** Defined by **Parametrial involvement** (but not reaching the pelvic wall). This is the most common stage where surgery is abandoned in favor of radiotherapy. * **Investigation of Choice for Staging:** MRI is the preferred imaging modality to assess local tumor extent and parametrial involvement. * **Radiotherapy Components:** CCRT typically involves a combination of External Beam Radiation Therapy (EBRT) and Brachytherapy.

Question 678: Cryosurgery is used in the treatment of cervical intraepithelial neoplasia. In which of the following conditions is cryosurgery NOT appropriate?

A. Transformation zone lying entirely on the ectocervix.
B. Smooth cervical surface without deep crevices.
C. Cervical intraepithelial neoplasia-3 (CIN-3). (Correct Answer)
D. CIN limited to two quadrants of the cervix.

Explanation: **Explanation:** Cryosurgery is an ablative technique used for treating Cervical Intraepithelial Neoplasia (CIN). Its success depends on the ability to freeze the entire transformation zone (TZ) and the lesion to a specific depth. **Why Option C is the correct answer:** Cryosurgery is generally **not recommended for CIN-3**. High-grade lesions (CIN-3) have a higher risk of harboring occult invasive carcinoma or extending deep into the endocervical crypts. Because cryosurgery is an ablative method, it does not provide a tissue specimen for histopathological verification of margins or to rule out invasion. For CIN-3, excisional procedures like LEEP (Loop Electrosurgical Excision Procedure) or Cold Knife Conization are preferred. **Analysis of Incorrect Options:** * **Option A:** Cryosurgery is ideal when the **TZ is entirely on the ectocervix** (Type 1 TZ). If the TZ extends into the endocervical canal, the cryoprobe cannot reach the upper limits, leading to treatment failure. * **Option B:** A **smooth cervical surface** ensures uniform contact between the cryoprobe and the tissue. Deep crevices or irregular contours prevent adequate freezing of the entire lesion. * **Option D:** Cryosurgery is most effective for **small lesions** (limited to <2 quadrants). Large lesions covering more than 75% of the cervix have a higher failure rate with ablation. **Clinical Pearls for NEET-PG:** * **Prerequisites for Cryosurgery:** Negative endocervical curettage (ECC), no evidence of malignancy, and a correlation between cytology and colposcopy. * **Technique:** The "Freeze-Thaw-Freeze" technique is used (3 mins freeze, 5 mins thaw, 3 mins freeze). * **Side Effect:** Patients often experience a profuse, watery vaginal discharge for 2–4 weeks post-procedure. * **Refrigerant:** Nitrous oxide ($N_2O$) or Carbon dioxide ($CO_2$) are commonly used.

Question 679: Which of the following histological features characterizes a hydatidiform mole?

A. Hyaline membrane degeneration
B. Hydropic degeneration of the villous stroma (Correct Answer)
C. Non-proliferation of cytotrophoblasts
D. Non-proliferation of syncytiotrophoblasts

Explanation: **Explanation:** The hallmark of a **Hydatidiform Mole** (Gestational Trophoblastic Disease) is the abnormal proliferation of trophoblastic tissue combined with fluid accumulation within the chorionic villi. **1. Why Option B is Correct:** The core pathology involves **hydropic degeneration**, where the villous stroma becomes edematous and swollen due to the accumulation of fluid. This leads to the formation of characteristic "grape-like" vesicles. Microscopically, this is accompanied by a lack of fetal blood vessels (avascular villi) and varying degrees of trophoblastic proliferation. **2. Why the Other Options are Incorrect:** * **Option A:** Hyaline membrane degeneration is typically associated with Respiratory Distress Syndrome (RDS) in neonates or certain chronic inflammatory processes, not molar pregnancies. * **Options C & D:** These are incorrect because **trophoblastic proliferation** (both cytotrophoblasts and syncytiotrophoblasts) is a defining feature of a mole. In a Complete Mole, there is circumferential proliferation of both layers; in a Partial Mole, the proliferation is usually focal and involves mainly the syncytiotrophoblast. **High-Yield NEET-PG Pearls:** * **Complete Mole:** 46 XX (most common), "Snowstorm appearance" on USG, markedly high hCG, no fetal parts, 15-20% risk of malignancy. * **Partial Mole:** 69 XXY (Triploidy), fetal parts present, focal hydropic changes, lower risk of malignancy (<5%). * **Karyotype:** Complete mole is entirely paternal in origin (androgenetic), whereas a partial mole involves one maternal and two paternal sets of chromosomes. * **Diagnosis:** Histopathology remains the gold standard, showing "cistern formation" (central fluid collection in villi).

Question 680: Abnormal vascular patterns seen with colposcopy in cases of cervical intraepithelial neoplasia are all except:

A. Punctation
B. Mosaicism
C. Satellite lesions (Correct Answer)
D. Atypical vessels

Explanation: In colposcopy, the identification of **abnormal vascular patterns** is critical for grading Cervical Intraepithelial Neoplasia (CIN) and identifying early invasive cancer. These patterns arise due to the pressure exerted by expanding neoplastic epithelium on the underlying stroma and its capillary bed. **Explanation of the Correct Answer:** * **C. Satellite lesions:** This is the correct answer because it is **not** a vascular pattern. Satellite lesions refer to a morphological distribution (multifocal areas of disease separated by normal tissue), which is more characteristic of Vulvar Intraepithelial Neoplasia (VIN) or certain infections (like Candidiasis), rather than a specific colposcopic vascular hallmark of CIN. **Explanation of Incorrect Options (Abnormal Vascular Patterns):** * **A. Punctation:** Caused by dilated capillary loops reaching the surface of the epithelium. On end-on view, they appear as red dots. Fine punctation suggests low-grade lesions (LSIL), while coarse punctation suggests high-grade lesions (HSIL). * **B. Mosaicism:** Occurs when capillaries surround "blocks" of acetowhite epithelium in a honeycomb or tile-like pattern. Like punctation, "coarse" mosaicism is a red flag for HSIL/CIN 3. * **D. Atypical vessels:** These are irregular, non-branching, "comma-shaped," "corkscrew," or "spaghetti-like" vessels. Their presence is highly suspicious for **invasive cervical carcinoma** rather than just CIN. **High-Yield Clinical Pearls for NEET-PG:** * **Reid Colposcopic Index (RCI):** Uses four criteria (Margin, Color, Vascular pattern, and Iodine staining) to grade lesions. * **Acetowhite Epithelium:** The most common colposcopic finding in CIN, caused by increased nuclear density. * **Green Filter:** Always used during colposcopy to enhance the contrast of red blood vessels, making punctation and mosaicism easier to visualize.

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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