Gynecologic Oncology Practice Questions

Q: Which of the following is true for benign ovarian tumors?

Capsule is intact. **Explanation:** **Correct Answer: B. Capsule is intact** Benign ovarian tumors are characterized by slow, expansive growth rather than infiltrative growth. This results in a well-defined, smooth, and **intact capsule**. In contrast, malignant tumors often exhibit capsular breach, surface excrescences, or invasion into surrounding pelvic structures. An intact capsule is a key surgical and pathological marker of benignity. **Analysis of Incorrect Options:** * **A. Torsion is uncommon:** This is false. Torsion is actually the **most common complication** of benign ovarian tumors (especially dermoid cysts). Because benign tumors are often mobile and pedunculated, they are more prone to twisting on their pedicle compared to malignant tumors, which are often fixed by adhesions or invasion. * **C. Ascites can occur:** While ascites is a classic hallmark of **malignancy** (due to peritoneal seeding), it is generally absent in benign cases. A notable exception is **Meigs’ Syndrome** (fibroma with ascites and pleural effusion), but as a general rule for NEET-PG, ascites points toward malignancy. * **D. Size is less than 10 cm:** Size is not a definitive criterion for benignity. Benign tumors, particularly **Mucinous Cystadenomas**, can reach massive proportions, often filling the entire abdominal cavity and exceeding 20–30 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor (all ages):** Serous cystadenoma. * **Most common benign tumor (reproductive age):** Mature cystic teratoma (Dermoid cyst). * **IOTA Simple Rules:** Benign features include unilocular cysts, presence of solid components <7mm, acoustic shadows, and no blood flow on Doppler. * **Tumor Markers:** CA-125 is often normal in benign tumors but can be elevated in endometriosis or PID.

Q: In a case of vesicular mole, all of the following are high-risk factors for the development of choriocarcinoma except:

Features of thyrotoxicosis. In the management of Hydatidiform Mole, identifying high-risk clinical features is crucial as they predict a 15–20% risk of progression to **Gestational Trophoblastic Neoplasia (GTN)**, specifically choriocarcinoma. ### **Why "Features of Thyrotoxicosis" is the Correct Answer** While thyrotoxicosis is a known complication of molar pregnancy (due to the structural similarity between the $\alpha$-subunit of hCG and TSH), it is considered a **medical complication** rather than a prognostic risk factor for malignancy. Its presence necessitates pre-operative stabilization with beta-blockers but does not increase the statistical likelihood of the mole becoming a choriocarcinoma. ### **Analysis of High-Risk Factors (Incorrect Options)** The following are established criteria for **"High-Risk Complete Mole"** (as defined by Goldstein and Berkowitz): * **Serum hCG > 100,000 mIU/mL:** Reflects massive trophoblastic proliferation and high tumor burden. * **Uterus size larger than dates (or > 16 weeks):** Rapid uterine enlargement indicates exuberant growth and a higher risk of post-evacuation persistent disease. * **Theca Lutein Cysts > 6 cm:** Bilateral ovarian enlargement due to hyperstimulation by high hCG levels is a significant marker for future malignant transformation. ### **Clinical Pearls for NEET-PG** * **Age Factor:** Maternal age > 40 years is also a major high-risk factor for GTN. * **The "Snowstorm Appearance":** The classic ultrasound finding for a complete mole. * **Follow-up Gold Standard:** Weekly serum hCG monitoring until three consecutive normal values are obtained is mandatory to rule out choriocarcinoma. * **Most Common Site of Metastasis:** The lungs (80%), followed by the vagina (30%).

Q: What is the marker for endodermal sinus tumor?

Alpha fetoprotein. **Explanation:** **Endodermal Sinus Tumor (Yolk Sac Tumor)** is the most common malignant germ cell tumor in children and young adults. It is derived from the primitive yolk sac, which physiologically produces **Alpha-fetoprotein (AFP)**. Consequently, AFP serves as a highly specific and sensitive serum marker for this tumor, used for both diagnosis and monitoring treatment response. Histologically, these tumors are characterized by the pathognomonic **Schiller-Duval bodies**. **Analysis of Incorrect Options:** * **B. HCG (Human Chorionic Gonadotropin):** This is the characteristic marker for **Choriocarcinoma**. While it can be elevated in some dysgerminomas (if syncytiotrophoblastic giant cells are present), it is not the primary marker for yolk sac tumors. * **C. LDH (Lactate Dehydrogenase):** This is a non-specific marker but is classically associated with **Dysgerminoma**. It reflects high cell turnover. * **D. CA-125:** This is the primary marker for **Epithelial Ovarian Tumors** (e.g., Serous Cystadenocarcinoma). It is generally not used for germ cell tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Schiller-Duval bodies:** Glomeruloid-like structures seen on histology in Yolk Sac Tumors. * **Dysgerminoma:** Most common malignant germ cell tumor in pregnancy; markers are **LDH** and **Inhibin**. * **Immature Teratoma:** Marker is often **AFP** (if yolk sac elements are present). * **Granulosa Cell Tumor:** Marker is **Inhibin B**. * **Rule of Thumb:** In a young girl with a rapidly growing ovarian mass and high AFP, always suspect Endodermal Sinus Tumor.

Q: Which drug is considered the best treatment for gestational trophoblastic disease presenting with jaundice?

Actinomycin-D. **Explanation:** The treatment of Gestational Trophoblastic Disease (GTD) is primarily determined by the risk score (WHO/FIGO scoring system). For low-risk non-metastatic or metastatic GTD, single-agent chemotherapy is the standard of care. **Why Actinomycin-D is the correct answer:** Methotrexate (MTX) and Actinomycin-D are the two primary first-line agents for low-risk GTD. However, **Methotrexate is hepatotoxic** and is primarily excreted by the kidneys. If a patient presents with **jaundice** (indicating hepatic dysfunction) or impaired liver function tests, Methotrexate is contraindicated. In such scenarios, **Actinomycin-D** becomes the drug of choice as it is safer and highly effective, with a slightly higher primary remission rate than MTX, though it carries more side effects (alopecia, nausea). **Analysis of Incorrect Options:** * **A. Methotrexate:** While it is often the first choice for low-risk GTD due to its low toxicity profile, it cannot be used in the presence of liver dysfunction (jaundice) or renal failure. * **B. Adriamycin (Doxorubicin):** This is an anthracycline used in various malignancies but is not a first-line agent for GTD. It is known for cardiotoxicity. * **D. Cyclophosphamide:** This is an alkylating agent used in multi-drug regimens (like EMA-CO) for high-risk GTD, but it is not the preferred single-agent treatment, especially when jaundice is the limiting factor for MTX. **NEET-PG High-Yield Pearls:** * **Drug of Choice for Low-Risk GTD:** Methotrexate (with Leucovorin rescue). * **Drug of Choice for GTD with Liver/Renal dysfunction:** Actinomycin-D. * **High-Risk GTD Treatment:** EMA-CO regimen (Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide, Oncovin/Vincristine). * **Most common site of metastasis:** Lungs (followed by the vagina). * **Follow-up marker:** Serial quantitative β-hCG levels.

Q: Inheritance is a major factor in which of the following conditions?

Endometrial carcinoma. **Explanation:** **1. Why Endometrial Carcinoma is the Correct Answer:** Inheritance plays a significant role in endometrial carcinoma, primarily through **Lynch Syndrome (Hereditary Non-Polyposis Colorectal Cancer - HNPCC)**. This autosomal dominant condition is caused by mutations in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, PMS2). Women with Lynch Syndrome have a **40–60% lifetime risk** of developing endometrial cancer, which often exceeds their risk of colorectal cancer. Additionally, Cowden Syndrome (PTEN mutation) also predisposes individuals to endometrial malignancy. **2. Why Other Options are Incorrect:** * **Cervical Carcinoma:** This is primarily an **infectious disease**, not a genetic one. Over 99% of cases are caused by persistent infection with **High-Risk Human Papillomavirus (HPV)**, specifically types 16 and 18. Risk factors are related to sexual behavior, parity, and smoking rather than inherited germline mutations. * **Both/None:** Since inheritance is a proven major factor for endometrial cancer but not for cervical cancer, these options are incorrect. **High-Yield Clinical Pearls for NEET-PG:** * **Lynch Syndrome:** The most common inherited predisposition to endometrial cancer. Screening involves annual endometrial biopsies starting at age 30–35. * **Type I vs. Type II Endometrial Cancer:** Type I (Endometrioid) is associated with estrogen excess and PTEN mutations, while Type II (Serous) is associated with p53 mutations. * **Protective Factors:** Combined Oral Contraceptive Pills (COCPs) significantly reduce the risk of endometrial cancer by providing progestational opposition to estrogen. * **Cervical Cancer:** The most common gynecological cancer in India; preventable via HPV vaccination and Pap smear screening.

Q: What is the essential investigation to be included in the follow-up of a hydatidiform mole?

Serum levels of HCG. ### Explanation **Correct Answer: C. Serum levels of HCG** The primary goal of follow-up after the evacuation of a hydatidiform mole is the early detection of **Gestational Trophoblastic Neoplasia (GTN)**. Since trophoblastic tissue (both benign and malignant) secretes Human Chorionic Gonadotropin (hCG), it serves as a highly sensitive and specific tumor marker. Serial quantitative serum beta-hCG levels are the "gold standard" to monitor for regression or persistence of the disease. A plateau or rise in these levels is the diagnostic criteria for post-molar GTN. **Why other options are incorrect:** * **A. Ultrasound of the abdomen:** While ultrasound is the investigation of choice for the *initial diagnosis* of a molar pregnancy ("snowstorm appearance"), it is not sensitive enough to detect microscopic persistent trophoblastic disease during follow-up. * **B. Chest X-ray:** This is performed at the time of diagnosis to rule out lung metastasis. However, it is not a routine serial investigation unless the hCG levels rise or the patient becomes symptomatic. * **D. Serum levels of TSH:** High levels of hCG can cross-react with TSH receptors (due to a common alpha subunit), leading to hyperthyroidism. While TSH is checked at diagnosis if the patient is symptomatic, it is not used to monitor for disease recurrence. **NEET-PG High-Yield Pearls:** * **Follow-up Protocol:** hCG levels should be monitored **weekly** until three consecutive results are negative ( 10% for 3 readings over 2 weeks, or 3) Persistence of hCG beyond 6 months.

Q: What is true about dysgerminoma?

Most common malignant germ cell tumor. **Explanation:** **Dysgerminoma** is the most common malignant germ cell tumor (GCT) of the ovary, accounting for approximately 50% of all malignant GCTs. It is the female counterpart of the testicular seminoma and typically affects young women in their teens and early twenties. * **Why Option B is correct:** Dysgerminoma is statistically the most frequent malignancy arising from germ cells. It is often associated with gonadal dysgenesis (e.g., Swyer syndrome). * **Why Option A is incorrect:** Dysgerminoma is famously **exquisitely radiosensitive**. However, because it primarily affects women of reproductive age, fertility-sparing surgery followed by chemotherapy (BEP regimen) is the preferred management to preserve the contralateral ovary and uterus. * **Why Option C is incorrect:** While it is the most common germ cell tumor to be bilateral (10–15% of cases), it is **predominantly unilateral** (85–90%). Therefore, "Bilateral" is not a defining characteristic compared to its status as the most common malignant GCT. * **Why Option D is incorrect:** The characteristic tumor marker for dysgerminoma is **LDH (Lactate Dehydrogenase)**. It may also show mild elevations in hCG. **Alpha-fetoprotein (AFP)** is the specific marker for Yolk Sac Tumors (Endodermal Sinus Tumors). **High-Yield Clinical Pearls for NEET-PG:** * **Microscopy:** Characterized by large, round, clear cells with central nuclei ("fried egg" appearance) separated by fibrous septa infiltrated with **lymphocytes**. * **Associated Condition:** Always rule out 46, XY karyotype (Gonadoblastoma) if a dysgerminoma is detected in a pre-pubertal girl. * **Treatment:** Most are Stage IA and treated with unilateral salpingo-oophorectomy. It has an excellent prognosis with a 5-year survival rate >95%.

Q: What is true about granulosa cell tumors?

They are chemotherapy sensitive.. **Explanation:** Granulosa cell tumors (GCTs) are the most common type of **sex cord-stromal tumors**. While they are often characterized by their indolent course and late recurrence, their management in advanced or recurrent stages relies heavily on their chemosensitivity. * **Why Option D is Correct:** GCTs are considered **chemosensitive**. For patients with high-risk Stage I or advanced/recurrent disease, platinum-based chemotherapy—specifically the **BEP regimen** (Bleomycin, Etoposide, and Cisplatin)—is the standard of care and shows high response rates. * **Why Option A is Incorrect:** The most common malignant tumors of the ovary are **Epithelial Ovarian Tumors** (specifically Serous Cystadenocarcinoma), not sex cord-stromal tumors. GCTs account for only about 2–5% of all ovarian malignancies. * **Why Option B & C are Incorrect (Contextual Note):** While GCTs *do* secrete estrogen and *are* associated with endometrial hyperplasia/carcinoma, these options are often considered "less true" or "incomplete" in the context of specific competitive exam framing if the question seeks the most definitive clinical management fact. *Note: In many clinical contexts, B and C are physiologically true; however, in NEET-PG, if D is the marked key, it emphasizes the therapeutic approach to malignancy.* **High-Yield Clinical Pearls for NEET-PG:** 1. **Pathognomonic Feature:** **Call-Exner bodies** (small follicles filled with eosinophilic material) and "coffee-bean" nuclei. 2. **Tumor Marker:** **Inhibin B** is the most reliable marker for diagnosis and monitoring recurrence. 3. **Clinical Presentation:** Often presents with **precocious puberty** (in juveniles) or **postmenopausal bleeding** (in adults) due to hyperestrogenism. 4. **Associated Pathology:** Up to 25–50% of cases are associated with endometrial hyperplasia, and 5% with endometrial carcinoma.

Q: A high-grade squamous intraepithelial lesion (HSIL) is noted on Pap smear. What is the next management step?

Colposcopy with biopsy. **Explanation:** The management of cervical cytological abnormalities follows a specific diagnostic algorithm. A Pap smear is a **screening tool**, not a diagnostic one. When a Pap smear shows **High-Grade Squamous Intraepithelial Lesion (HSIL)**, it indicates a high probability of underlying high-grade cervical intraepithelial neoplasia (CIN 2/3) or even occult invasive cancer. **1. Why Colposcopy with Biopsy is correct:** According to ASCCP guidelines, any high-grade screening result (HSIL, ASC-H, or AGC) requires immediate **Colposcopy**. Colposcopy allows for the visualization of the transformation zone under magnification. If an abnormal area is identified (e.g., punctations, mosaicism, or dense acetowhite epithelium), a **directed biopsy** is performed to obtain a tissue diagnosis. Management is based on the histological grade (CIN) rather than the cytological smear. **2. Why other options are incorrect:** * **Wertheim’s Hysterectomy:** This is a radical surgery for invasive cervical cancer (Stage IA2-IIA). It is never performed based solely on a screening Pap smear without a histological diagnosis of malignancy. * **Local Excision (LEEP/Cold Knife Conization):** While HSIL may eventually require an excisional procedure (See-and-Treat), the standard initial step is diagnostic confirmation via colposcopy. * **HPV DNA Testing:** This is used for "reflex testing" in low-grade lesions (ASC-US). In HSIL, the risk of high-risk HPV is already so high that testing adds no clinical value to the management. **Clinical Pearls for NEET-PG:** * **ASC-US:** Next step is HPV DNA testing (if positive → Colposcopy; if negative → repeat Pap in 3 years). * **HSIL in Pregnancy:** Colposcopy is mandatory, but biopsy is only done if invasive cancer is suspected. Endocervical curettage (ECC) is **contraindicated** in pregnancy. * **Gold Standard for Diagnosis:** Cervical Biopsy (Colposcopy-directed).

Question 1

Which of the following is true for benign ovarian tumors?

Accepted Answer

Capsule is intact

Answer

Torsion is uncommon

Answer

Ascites can occur

Answer

Size is less than 10 cm

Question 2

In a case of vesicular mole, all of the following are high-risk factors for the development of choriocarcinoma except:

Accepted Answer

Features of thyrotoxicosis

Answer

Serum hCG levels > 100000 mIU/mL

Answer

Uterus size larger than 16 weeks

Answer

Presence of bilateral theca lutein cysts of the ovary

Question 3

What is the marker for endodermal sinus tumor?

Accepted Answer

Alpha fetoprotein

Answer

HCG

Answer

LDH

Answer

CA-125

Question 4

Which drug is considered the best treatment for gestational trophoblastic disease presenting with jaundice?

Accepted Answer

Actinomycin-D

Answer

Methotrexate

Answer

Adriamycin

Answer

Cyclophosphamide

Question 5

Inheritance is a major factor in which of the following conditions?

Accepted Answer

Endometrial carcinoma

Answer

Cervical carcinoma

Answer

Both

Answer

None

Question 6

What is the essential investigation to be included in the follow-up of a hydatidiform mole?

Accepted Answer

Serum levels of HCG

Answer

Ultrasound of the abdomen

Answer

Chest X-ray

Answer

Serum levels of TSH

Question 7

What is true about dysgerminoma?

Accepted Answer

Most common malignant germ cell tumor

Answer

Insensitive to radiotherapy

Answer

Bilateral

Answer

Alpha-fetoprotein is the tumor marker

Question 8

The presence of lutein cysts in a vesicular mole is due to excess of which hormone?

Accepted Answer

Human chorionic gonadotropin (HCG)

Answer

Follicle-stimulating hormone (FSH)

Answer

Luteinizing hormone (LH)

Answer

Estrogen

Question 9

What is true about granulosa cell tumors?

Accepted Answer

They are chemotherapy sensitive.

Answer

They are the most common malignant tumor of the ovary.

Answer

They secrete hormones.

Answer

They are associated with endometrial hyperplasia.

Question 10

A high-grade squamous intraepithelial lesion (HSIL) is noted on Pap smear. What is the next management step?

Accepted Answer

Colposcopy with biopsy

Answer

Wertheim's hysterectomy

Answer

Local excision

Answer

HPV DNA testing

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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