Gynecologic Oncology Practice Questions

Q: A 60-year-old lady is diagnosed with carcinoma of the endometrium with involvement of more than 50% of the myometrium and vagina. The carcinoma has not involved pelvic and para-aortic lymph nodes, and peritoneal cytology is positive. What is the stage of her malignancy?

Stage IIIb. **Explanation:** The staging of endometrial carcinoma is based on the **FIGO Staging System (Revised 2023/2009)**. In this clinical scenario, the key finding is the involvement of the **vagina**, which automatically classifies the malignancy as **Stage IIIb**. 1. **Why Stage IIIb is correct:** According to FIGO staging, Stage III denotes local and/or regional spread of the tumor. Specifically: * **Stage IIIa:** Tumor involves serosa or adnexa. * **Stage IIIb:** Tumor involves the **vagina** and/or parametrium. * Since this patient has vaginal involvement, she is classified as Stage IIIb, regardless of the myometrial invasion depth or positive peritoneal cytology (which is no longer used to upstage disease in the 2009/2023 criteria but is noted). 2. **Why other options are incorrect:** * **Stage Ib:** This involves invasion of $\geq$ 50% of the myometrium but is strictly confined to the **corpus uteri**. The presence of vaginal spread excludes Stage I. * **Stage IIIc:** This stage is reserved for metastasis to the **pelvic (IIIc1) or para-aortic (IIIc2) lymph nodes**. The question explicitly states these nodes are not involved. * **Stage IVa:** This represents advanced spread to the **bladder or bowel mucosa**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Postmenopausal bleeding (PMB). * **Most common histological type:** Endometrioid adenocarcinoma. * **Staging Method:** Endometrial cancer is **surgically staged** (unlike cervical cancer, which was historically clinically staged). * **Peritoneal Cytology:** While recorded, positive cytology alone does not change the FIGO stage; however, vaginal or parametrial involvement (IIIb) is a significant prognostic indicator.

Q: What is the investigation of choice for cervical neoplasm?

Cone biopsy. **Explanation:** The "Investigation of Choice" (IOC) for cervical neoplasm refers to the **Gold Standard** method required for a definitive diagnosis and staging. 1. **Why Cone Biopsy is Correct:** While a punch biopsy can diagnose invasive cancer, a **Cone Biopsy** (Cold knife conization or LEEP) is the definitive investigation. It provides a large tissue specimen that allows the pathologist to evaluate the entire transformation zone, the depth of stromal invasion, and the presence of lymphovascular space invasion (LVSI). It is both diagnostic and, in cases of microinvasive carcinoma (Stage IA1), therapeutic. 2. **Why Other Options are Incorrect:** * **Pap Smear:** This is a **screening tool**, not a diagnostic one. It identifies cytological abnormalities but cannot confirm the stage or depth of invasion. * **Speculoscopy & Cervicography:** These are adjunct visual screening methods used to enhance the detection of lesions. They lack the histological precision required for a definitive diagnosis of neoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Test of Choice:** Pap Smear (Liquid-based cytology is preferred). * **Best Screening Strategy:** Co-testing (Pap smear + HPV DNA testing) every 5 years for women aged 30–65. * **Initial Investigation for Abnormal Pap:** Colposcopy-directed biopsy. * **IOC for Microinvasive Carcinoma:** Cone Biopsy (to rule out deeper invasion). * **Staging:** Cervical cancer is staged **Clinically** (FIGO staging), though the 2018 update allows for imaging (MRI/CT) and pathological findings where available.

Q: Which of the following statements regarding vulval carcinoma is FALSE?

Lichen planus predisposes to vulval carcinoma.. **Explanation:** Vulval carcinoma primarily arises through two distinct pathways: the **HPV-dependent pathway** (associated with high-risk HPV types 16 and 18) and the **HPV-independent pathway** (associated with chronic inflammatory conditions). **Why Option C is the False Statement:** While **Lichen Sclerosus** is a well-documented precursor to the HPV-independent (differentiated) type of vulval squamous cell carcinoma (SCC), **Lichen Planus** is generally considered to have a negligible or questionable association with vulval malignancy. In the context of NEET-PG, Lichen Sclerosus is the high-yield "Lichen" associated with cancer, not Lichen Planus. **Analysis of Other Options:** * **Option A (Squamous Hyperplasia):** Also known as Lichen Simplex Chronicus, this condition involves chronic irritation and itching. It is frequently found in the vicinity of vulval SCC and is considered a predisposing factor. * **Option B (Paget’s Disease):** Extramammary Paget’s disease of the vulva is an intraepithelial neoplasia. In approximately 10-20% of cases, it is associated with an underlying invasive adenocarcinoma of the vulva or adnexal structures. * **Option D (Condylomata Acuminata):** These are genital warts caused by HPV (usually low-risk types 6 and 11). However, patients with Condylomata often have co-infections with high-risk HPV types, which can lead to Vulval Intraepithelial Neoplasia (VIN) and eventually invasive carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Squamous Cell Carcinoma (85-90%). * **Most common site:** Labia majora. * **Precursor lesions:** VIN (Usual type - HPV related; Differentiated type - Lichen Sclerosus related). * **Staging:** Vulval cancer is staged **Surgically** (FIGO). * **Lymphatic spread:** The primary route of spread is to the **Inguinal-Femoral lymph nodes** (Sentinel nodes are often evaluated).

Q: What is the ideal treatment for a 55-year-old female with endometrial hyperplasia with atypia?

Simple hysterectomy. **Explanation:** The management of endometrial hyperplasia is determined by the presence or absence of **cellular atypia** and the patient’s reproductive goals. **Why Simple Hysterectomy is the Correct Choice:** Endometrial hyperplasia with atypia (EIN - Endometrial Intraepithelial Neoplasia) is considered a **premalignant lesion**. It carries a high risk (up to 30–40%) of progressing to or coexisting with an undiagnosed endometrioid adenocarcinoma. For a 55-year-old (postmenopausal) woman who has completed her family, **Total Abdominal Hysterectomy (Simple Hysterectomy)** is the definitive treatment of choice to eliminate the risk of malignancy. Bilateral Salpingo-oophorectomy (BSO) is also typically performed in this age group. **Why Other Options are Incorrect:** * **B & C (Progesterones):** Medroxyprogesterone acetate and Levonorgestrel (LNG-IUS) are the mainstays for hyperplasia **without** atypia. While they can be used for atypical hyperplasia in young patients wishing to preserve fertility or those unfit for surgery, they are not the "ideal" or first-line treatment for a postmenopausal woman due to the high risk of occult cancer. * **D (IUCD):** A standard non-medicated IUCD has no therapeutic role in treating endometrial hyperplasia. Only the hormone-releasing system (LNG-IUS) is used. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperplasia WITHOUT atypia:** Risk of progression to cancer is 4 mm in a symptomatic postmenopausal woman requires biopsy.

Q: What is the most common site of metastasis for carcinoma of the cervix?

Lungs. **Explanation:** In the context of **distant (hematogenous) metastasis**, the **lungs** are the most common site for carcinoma of the cervix. While cervical cancer primarily spreads via direct local extension and the lymphatic system, once it enters the bloodstream, the pulmonary vasculature acts as the first filter, making the lungs the most frequent site for distant deposits. **Analysis of Options:** * **B. Lungs (Correct):** Studies and clinical data consistently show that the lungs are the most frequent site of extra-pelvic, distant spread (followed by the liver and bone). * **A. Lymph Nodes:** While lymph nodes are the **most common overall route of spread** (starting with paracervical, then obturator and external iliac nodes), the question specifically asks for a "site of metastasis." In standard oncology nomenclature for NEET-PG, when "site of metastasis" is used in this context, it refers to distant organ involvement rather than the primary mode of spread. * **C. Bone:** This is the third most common site for distant metastasis. Bone involvement (usually the spine or pelvis) typically occurs in advanced stages and carries a poor prognosis. * **D. Abdominal Cavity:** While peritoneal seeding can occur in advanced stages (Stage IVB), it is less common than hematogenous spread to the lungs. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Route of Spread:** Direct extension (most common) > Lymphatic > Hematogenous. * **First Lymph Node Involved:** Paracervical/Obturator nodes. * **Sentinel Node:** The node most likely to first receive drainage (usually the medial external iliac or obturator node). * **Staging:** Cervical cancer is now staged **clinically and radiologically** (FIGO 2018), allowing for MRI/CT findings to influence the stage. * **Most Common Cause of Death:** Uremia due to bilateral ureteric obstruction (leading to post-renal renal failure).

Q: A 45-year-old patient presents to the Gynecology OPD with a history of postcoital bleeding. She underwent the procedure shown below. Name the instruments used.

Ayre's spatula, Cusco's speculum. ***Ayre's spatula, Cusco's speculum*** - **Ayre's spatula** is the standard instrument for collecting **ectocervical cells** during a Pap smear, essential for screening cervical cancer in patients with postcoital bleeding. - **Cusco's speculum** provides optimal **visualization** and **access** to the cervix, allowing proper sample collection from the transformation zone. *Cervical pipette, Sim's speculum* - **Cervical pipette** is primarily used for **endometrial sampling**, not for routine cervical cytology screening. - **Sim's speculum** is a **single-blade speculum** that provides limited visualization compared to the bivalve Cusco's speculum. *Endocervical brush, Sim's speculum* - **Endocervical brush** alone is insufficient as it only samples the **endocervical canal**, missing the important **ectocervical** transformation zone. - **Sim's speculum** offers **inadequate exposure** of the cervix for proper cytological sampling. *Cusco's speculum, Endocervical brush* - While **Cusco's speculum** is correct, using only an **endocervical brush** misses the **ectocervical** cells from the transformation zone. - **Ayre's spatula** is essential for collecting cells from the **squamocolumnar junction** where most cervical cancers originate.

Q: For a woman with a history of two prior molar pregnancies, what is the risk of having a third molar pregnancy?

20%. **Explanation:** The risk of recurrent gestational trophoblastic disease (GTD) increases significantly with each subsequent molar pregnancy. This question tests the candidate's knowledge of the specific statistical progression of recurrence risk. **1. Why 20% is Correct:** The baseline risk of a molar pregnancy in the general population is approximately **0.1% (1 in 1000)**. * After **one** molar pregnancy, the risk of recurrence rises to **1%** (a 10-fold increase). * After **two** prior molar pregnancies, the risk jumps significantly to **15–20%**. This exponential increase is likely due to underlying genetic predispositions or oocyte defects that favor abnormal fertilization. **2. Analysis of Incorrect Options:** * **A (1%):** This is the risk of recurrence after only **one** prior molar pregnancy. * **B (5%) & C (10%):** These values underestimate the risk. While recurrence risks for many obstetric complications (like preeclampsia) fall in this range, molar pregnancy recurrence follows a much steeper trajectory after the second event. **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Most Common Type:** The most common karyotype for a **Complete Mole** is 46,XX (androgenetic), while a **Partial Mole** is typically 69,XXX or 69,XXY (triploid). * **Management of Future Pregnancies:** For patients with a history of mole, an early ultrasound (6–10 weeks) is mandatory in all subsequent pregnancies to confirm normalcy. * **Post-Evacuation Monitoring:** After evacuation, serum β-hCG should be monitored weekly until three consecutive negative results are obtained, then monthly (6 months for complete mole). * **Contraception:** Combined Oral Contraceptive Pills (OCPs) are the preferred method once hCG levels become undetectable; they do not increase the risk of post-molar trophoblastic neoplasia.

Q: A patient with carcinoma of the cervix, who has completed radiotherapy, presents with uremia. What is the most common cause of this presentation?

Bilateral ureteral invasion. **Explanation:** In advanced carcinoma of the cervix, the most common cause of death and a frequent cause of renal failure (uremia) is **bilateral ureteral obstruction**. **1. Why Option A is Correct:** Cervical cancer typically spreads laterally via the parametrium. As the tumor infiltrates the parametrial tissues, it can compress or directly invade the ureters at the point where they pass under the uterine artery ("water under the bridge"). When this occurs bilaterally, it leads to obstructive uropathy, hydronephrosis, and eventually uremia. Even after radiotherapy, persistent or recurrent disease is the most statistically likely cause of new-onset uremia in these patients. **2. Why Other Options are Incorrect:** * **Radiation Nephritis (B):** This occurs when the kidneys are directly in the radiation field (e.g., treating upper abdominal tumors). In cervical cancer, the radiation is focused on the pelvis, sparing the kidneys. * **Ureteral Stenosis due to Radiation (C):** While radiation-induced fibrosis can cause ureteral strictures, it is significantly less common than direct tumor invasion or recurrence. * **Unconnected Causes (D):** While possible, they are not the "most common" cause in the context of a known cervical malignancy. **Clinical Pearls for NEET-PG:** * **Most common cause of death in Cervical CA:** Uremia (Renal failure) due to bilateral ureteral obstruction. * **Staging Significance:** Ureteral involvement (hydronephrosis or non-functioning kidney) automatically classifies the disease as **Stage IIIB**, regardless of other findings. * **Triad of Advanced Pelvic Malignancy:** Leg edema, hydronephrosis, and sciatic pain (indicates lateral pelvic wall involvement).

Question 1

A 60-year-old lady is diagnosed with carcinoma of the endometrium with involvement of more than 50% of the myometrium and vagina. The carcinoma has not involved pelvic and para-aortic lymph nodes, and peritoneal cytology is positive. What is the stage of her malignancy?

Accepted Answer

Stage IIIb

Answer

Stage Ib

Answer

Stage IIIc

Answer

Stage IVa

Question 2

What is the investigation of choice for cervical neoplasm?

Accepted Answer

Cone biopsy

Answer

Speculoscopy

Answer

Pap smear

Answer

Cervicography

Question 3

Which of the following statements regarding vulval carcinoma is FALSE?

Accepted Answer

Lichen planus predisposes to vulval carcinoma.

Answer

Squamous hyperplasia predisposes to vulval carcinoma.

Answer

Paget's disease of the vulva predisposes to vulval carcinoma.

Answer

Condylomata acuminata predisposes to vulval carcinoma.

Question 4

What is the ideal treatment for a 55-year-old female with endometrial hyperplasia with atypia?

Accepted Answer

Simple hysterectomy

Answer

Medroxyprogesterone acetate

Answer

Levonorgestrel

Answer

Intrauterine contraceptive device (IUCD)

Question 5

What is the most common site of metastasis for carcinoma of the cervix?

Accepted Answer

Lungs

Answer

Lymph nodes

Answer

Bone

Answer

Abdominal cavity

Question 6

A 45-year-old patient presents to the Gynecology OPD with a history of postcoital bleeding. She underwent the procedure shown below. Name the instruments used.

Accepted Answer

Ayre's spatula, Cusco's speculum

Answer

Cervical pipette, Sim's speculum

Answer

Endocervical brush, Sim's speculum

Answer

Cusco's speculum, Endocervical brush

Question 7

For a woman with a history of two prior molar pregnancies, what is the risk of having a third molar pregnancy?

Accepted Answer

20%

Answer

1%

Answer

5%

Answer

10%

Question 8

Regarding adenocarcinoma in situ, all are true, except:

Accepted Answer

Negative margins on an excised specimen ensures complete resection of the disease.

Answer

Invasive cancer cannot be ruled out without diagnostic excisional procedures.

Answer

Hysterectomy is preferred for women who have completed childbearing.

Answer

Frequently extends into the endocervical canal.

Question 9

A 25-year-old woman undergoes a Pap smear at a screening camp for cervical cancer. Her test report indicates inadequate cervical cytology. What is the appropriate follow-up for this patient?

Accepted Answer

Repeat cervical cytology in 3 months

Answer

Refer for colposcopy

Answer

Repeat cervical cytology in 6 months

Answer

Repeat cervical cytology in 3 years

Question 10

A patient with carcinoma of the cervix, who has completed radiotherapy, presents with uremia. What is the most common cause of this presentation?

Accepted Answer

Bilateral ureteral invasion

Answer

Radiation nephritis

Answer

Ureteral stenosis due to radiation

Answer

Unconnected causes

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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