Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 701: A 35-year-old woman who has completed her family shows a positive Pap smear (Cervical intraepithelial neoplasia III (CIN III)). What is to be done next?

A. Wertheim's hysterectomy
B. Simple hysterectomy (Correct Answer)
C. Cryotherapy
D. Conisation

Explanation: ***Simple hysterectomy*** - **Simple (total) hysterectomy** is the **definitive treatment of choice** for **CIN III** in a woman who has **completed her family**. - It removes the **entire uterus and cervix**, eliminating the risk of **recurrence or progression** to invasive cancer. - This provides a **permanent cure** without the need for long-term surveillance required after excisional procedures. - Preferred over conisation in this scenario as **fertility preservation is not needed**. *Conisation* - **Conisation** (cone biopsy) is an excisional procedure that removes a cone-shaped piece of cervical tissue and is the **treatment of choice for CIN III when fertility preservation is desired**. - While it can be both diagnostic and therapeutic, it has a **10-15% recurrence rate** and requires **lifelong cervical surveillance**. - In a patient who has **completed her family**, a more definitive treatment (hysterectomy) is preferred over conisation. *Wertheim's hysterectomy* - **Wertheim's hysterectomy** (radical hysterectomy with pelvic lymphadenectomy) is indicated for **invasive cervical cancer** (Stage IA2-IIA). - **CIN III is a pre-invasive lesion**, not invasive cancer, making this procedure unnecessarily radical and associated with significant morbidity. - This would only be considered if invasion is confirmed on histopathology. *Cryotherapy* - **Cryotherapy** is an **ablative treatment** that destroys abnormal cervical tissue by freezing. - It is suitable for **CIN I or CIN II** with small lesions but is **inadequate for CIN III** due to: - Higher risk of **residual disease** (cannot assess depth of involvement) - **No histological specimen** obtained for margin assessment - Higher recurrence rates compared to excisional procedures

Question 702: The risk of progression to endometrial cancer from simple hyperplasia without atypia is

A. 8-10%
B. 25-30%
C. 1% (Correct Answer)
D. 3-5%

Explanation: ***1%*** - The risk of **simple endometrial hyperplasia without atypia** progressing to endometrial cancer is very low, typically cited as less than 1%. - This low risk is why conservative management and surveillance are often sufficient for this type of hyperplasia. *8-10%* - This percentage is more indicative of the risk of progression for **complex endometrial hyperplasia without atypia**, which has a higher propensity for malignant transformation. - Simple hyperplasia without atypia carries a much lower risk due to its less abnormal glandular architecture and lack of cytologic atypia. *25-30%* - This value represents the risk of progression for **atypical endometrial hyperplasia (endometrial intraepithelial neoplasia)**, which is considered a precursor lesion to endometrial cancer. - The presence of **cytological atypia** significantly increases the risk of malignant transformation. *3-5%* - This risk range is typically associated with **complex endometrial hyperplasia without atypia**, which is higher than simple hyperplasia but considerably lower than atypical hyperplasia. - While it has abnormal architectural features, the absence of **cellular atypia** keeps the risk below that of atypical lesions.

Question 703: A 26 year old woman P1L1 reports with High Grade Squamous Intraepithelial Lesion (HGSIL) on Pap smear (Papanicolaou smear). Further management for her is:

A. Colposcopy and directed biopsy (Correct Answer)
B. Conisation
C. VIA, VILI
D. LEEP

Explanation: ***Colposcopy and directed biopsy*** - A diagnosis of **High-Grade Squamous Intraepithelial Lesion (HGSIL)** from a Pap smear necessitates further investigation with **colposcopy**. - **Colposcopy** allows for direct visualization of the cervix, and **directed biopsies** are taken from suspicious areas to confirm the diagnosis and assess the extent of the lesion. *Conisation* - **Conisation (cone biopsy)** is a surgical procedure to remove a cone-shaped piece of tissue from the cervix. - It is typically performed *after* colposcopy and biopsy have confirmed a high-grade lesion or cervical cancer, not as the initial diagnostic step for HGSIL. *VIA, VILI* - **Visual inspection with acetic acid (VIA)** and **visual inspection with Lugol's iodine (VILI)** are screening methods for cervical cancer, particularly in resource-limited settings. - While useful for screening, they are not appropriate for managing a confirmed HGSIL diagnosis, which requires a more precise evaluation. *LEEP* - **LEEP (Loop Electrosurgical Excision Procedure)** is a common treatment for HGSIL. - Like conisation, LEEP is a therapeutic procedure used *after* a definitive diagnosis has been made through colposcopy and biopsy, not as the initial step for evaluating an HGSIL Pap smear.

Question 704: Surgical staging is done for all the genital malignancies EXCEPT:

A. Gestational trophoblastic neoplasia (Correct Answer)
B. Fallopian tube malignancy
C. Endometrial carcinoma
D. Ovarian malignancy

Explanation: ***Gestational trophoblastic neoplasia*** - Gestational trophoblastic neoplasia (GTN) is primarily staged **clinically** and **biochemically** using beta-human chorionic gonadotropin (β-hCG) levels. - **Surgical staging is not typically performed** for GTN due to its high sensitivity to chemotherapy and its hematogenous spread pattern. *Fallopian tube malignancy* - **Surgical staging is essential** for fallopian tube malignancy to determine disease extent and guide treatment. - Staging often involves **laparotomy**, histological examination, and evaluation of surrounding tissues. *Endometrial carcinoma* - **Surgical staging is the cornerstone of management** for endometrial carcinoma, as it provides crucial prognostic information. - This typically includes **hysterectomy**, bilateral salpingo-oophorectomy, and lymph node dissection. *Ovarian malignancy* - **Comprehensive surgical staging** is standard for ovarian malignancy to assess the spread of the disease within the peritoneal cavity. - This involves **laparotomy**, biopsies, and often extensive debulking procedures.

Question 705: A 50 year old P4L4 has a simple left ovarian cyst of 10cm. Ca 125 is 30u/ml. Treatment of choice would be:

A. Medical management with oral contraceptives
B. Laparoscopic cystectomy
C. TAH + BSO (Total abdominal hysterectomy + Bilateral salpingo-oophorectomy)
D. Laparoscopic bilateral oophorectomy (BSO) (Correct Answer)

Explanation: ***Laparoscopic bilateral oophorectomy (BSO)*** - For a 50-year-old postmenopausal woman (P4L4) with a **simple ovarian cyst** of 10cm and **normal CA-125** (30 u/ml), **laparoscopic bilateral salpingo-oophorectomy (BSO)** is the treatment of choice. - **Bilateral removal** is preferred in postmenopausal women to eliminate future ovarian cancer risk and prevent contralateral ovarian pathology, as the ovaries no longer have hormonal function. - **Laparoscopic approach** provides adequate treatment with minimal morbidity, faster recovery, and lower complication rates compared to laparotomy. - The **normal CA-125** and **simple cyst characteristics** suggest benign pathology, making minimally invasive surgery appropriate. *Medical management with oral contraceptives* - **Oral contraceptives** are contraindicated in postmenopausal women and ineffective for simple ovarian cysts in this age group. - OCPs work on functional cysts in premenopausal women but have no role in postmenopausal ovarian masses. - Increased **thromboembolic risk** in women over 50 makes OCPs inappropriate. *TAH + BSO (Total abdominal hysterectomy + Bilateral salpingo-oophorectomy)* - While BSO is appropriate, adding **hysterectomy is unnecessary** for isolated ovarian pathology and increases surgical morbidity. - **Open approach** (laparotomy) carries higher complication rates, longer hospital stay, and prolonged recovery compared to laparoscopy. - Current guidelines favor **minimally invasive surgery** when feasible for benign-appearing ovarian masses. *Laparoscopic cystectomy* - **Cystectomy alone** (ovarian preservation) is inappropriate in a 50-year-old postmenopausal woman as it leaves ovarian tissue at risk for future malignancy. - This fertility-preserving approach is only indicated in younger women desiring fertility; at age 50 post-menopause, **complete bilateral oophorectomy** is standard of care to reduce ovarian cancer risk.

Question 706: A 47 year old post menopausal lady was on adjuvant hormonal treatment with Tamoxifen for 3 years for Carcinoma Breast. She came to Outpatient Department with history of passing blood clots per vagina. She is probably suffering from:

A. Uterine fibroid
B. Carcinoma Endometrium (Correct Answer)
C. Carcinoma Vagina
D. Carcinoma Vulva

Explanation: ***Carcinoma Endometrium*** - **Tamoxifen** acts as an **estrogen agonist** in the endometrium, increasing the risk of **endometrial hyperplasia** and **carcinoma**. - Postmenopausal vaginal bleeding or passing blood clots is a significant warning sign for **endometrial cancer**. *Uterine fibroid* - While fibroids can cause abnormal uterine bleeding, they are less likely to cause sudden, significant bleeding with clots in a **postmenopausal woman** on Tamoxifen without other symptoms. - Tamoxifen is not a direct cause of uterine fibroid development or enlargement. *Carcinoma Vagina* - **Vaginal carcinoma** is rarer than endometrial carcinoma and typically presents with a **vaginal mass** or bleeding with intercourse, not usually significant clotting in this context. - Tamoxifen is not directly linked to an increased risk of primary vaginal carcinoma. *Carcinoma Vulva* - **Vulvar carcinoma** presents as a **lesion** or **sore on the vulva** and symptoms like itching, pain, or bleeding from the lesion itself, not typically as vaginal blood clots. - The use of Tamoxifen does not significantly increase the risk of vulvar carcinoma.

Question 707: Which of the following is NOT a high risk factor for developing endometrial carcinoma?

A. Delayed menopause
B. Hypertension
C. Multiparity (Correct Answer)
D. Obesity

Explanation: ***Multiparity*** - **Multiparity** (having multiple live births) is generally considered a **protective factor** against endometrial carcinoma, as it leads to periods of reduced estrogen exposure. - Frequent pregnancies interrupt prolonged exposure to unopposed estrogen, which is a major driver of endometrial proliferation. *Delayed menopause* - **Delayed menopause** increases the total lifetime exposure to **endogenous estrogen**, which is a significant risk factor for endometrial carcinoma. - Prolonged estrogen exposure without sufficient progesterone to balance its effects promotes endometrial hyperplasia and potential malignant transformation. *Hypertension* - **Hypertension** is an independent risk factor for endometrial carcinoma, often associated with other metabolic conditions like **obesity** and **diabetes**. - It contributes to a pro-inflammatory and pro-carcinogenic environment, although the exact mechanisms are complex and involve hormonal and metabolic pathways. *Obesity* - **Obesity** is a major risk factor due to the increased peripheral conversion of androgens to **estrogen** in adipose tissue. - Higher levels of estrogen lead to **unopposed estrogen stimulation** of the endometrium, promoting hyperplasia and increasing the risk of carcinoma.

Question 708: A 65 year old postmenopausal lady presents in Gynaecology OPD with abdominal distension and weight loss. On investigation she was diagnosed to have an ovarian tumour. The most common type of ovarian tumour in this woman would be

A. Sex cord tumor
B. Epithelial tumor (Correct Answer)
C. Germ cell tumor
D. Trophoblastic tumor

Explanation: ***Epithelial tumor*** - **Epithelial ovarian tumors** are the most common type of ovarian cancer, accounting for about **90%** of all cases. - Their incidence significantly increases with age, particularly in **postmenopausal women**, making them the most likely diagnosis in a 65-year-old presenting with abdominal distension and weight loss. *Sex cord tumor* - **Sex cord-stromal tumors** are rare, comprising about **5-8%** of ovarian neoplasms. - While they can occur at any age, they are less common than epithelial tumors and often present with **hormonal symptoms** due to their steroidogenic capacity. *Germ cell tumor* - **Germ cell tumors** are also rare, primarily affecting **younger women and adolescents**, typically under 30 years old. - They tend to grow rapidly and can present with acute symptoms like sudden onset abdominal pain, which is less characteristic for a 65-year-old postmenopausal woman. *Trophoblastic tumor* - **Trophoblastic tumors** (specifically **gestational trophoblastic disease**) are primarily related to pregnancy and occur when there is abnormal proliferation of trophoblastic tissue, such as in a **hydatidiform mole** or **choriocarcinoma**. - These are extremely rare in a postmenopausal woman without a recent pregnancy history and are not considered ovarian tumors in the traditional sense.

Question 709: Carcinoma of endometrium is associated with the following risk factors except:

A. Multiparity (Correct Answer)
B. Hypertension
C. Obesity
D. Diabetes

Explanation: ***Multiparity*** - **Multiparity**, defined as having given birth to multiple children, is generally considered a protective factor or to have no significant association with endometrial cancer. - Reduced exposure to unopposed **estrogen** due to more frequent anovulation or hormonal changes during and after pregnancy may contribute to this protective effect. *Hypertension* - **Hypertension** is a known risk factor for endometrial cancer, possibly due to its association with **obesity** and metabolic syndrome, which increase endogenous estrogen levels. - The exact mechanism is not fully understood, but it is thought to be part of the complex interplay of metabolic factors. *Obesity* - **Obesity** is a strong and well-established risk factor for endometrial cancer, as adipose tissue converts androgens into **estrogens** (via aromatase), leading to unopposed estrogen stimulation of the endometrium. - Higher levels of **insulin-like growth factors** in obese individuals may also promote endometrial cell proliferation. *Diabetes* - **Diabetes mellitus**, particularly type 2, is associated with an increased risk of endometrial cancer, largely due to **hyperinsulinemia** and insulin resistance. - **Insulin** acts as a growth factor, promoting endometrial cell proliferation and potentially contributing to malignant transformation.

Question 710: An adolescent girl with stage 1a dysgerminoma is managed by:

A. Chemotherapy
B. Bilateral salpingo-oophorectomy alone
C. Total abdominal hysterectomy with unilateral salpingo-oophorectomy
D. Unilateral salpingo-oophorectomy alone (Correct Answer)

Explanation: ***Unilateral salpingo-oophorectomy alone*** - For **stage 1a dysgerminoma**, which is confined to one ovary, **fertility-sparing surgery** with unilateral salpingo-oophorectomy is the standard treatment, especially in young patients. - This approach aims to preserve reproductive function while effectively treating the localized tumor, given the **high radiosensitivity** and **chemosensitivity** of dysgerminomas. *Chemotherapy* - While dysgerminomas are sensitive to chemotherapy, it is typically reserved for **advanced stages** (stage 1c or higher), **recurrent disease**, or cases with **residual disease** after surgery. - It is not the primary treatment for **stage 1a disease** when complete surgical resection is achievable, especially when fertility preservation is desired. *Bilateral salpingo-oophorectomy alone* - This procedure would remove both ovaries and fallopian tubes, leading to **sterility and premature menopause**. - It is an **over-treatment** for stage 1a dysgerminoma, as the disease is localized to one ovary, and it is not fertility-sparing. *Total abdominal hysterectomy with unilateral salpingo-oophorectomy* - This extensive surgery involves the removal of the uterus and one ovary/fallopian tube, rendering the patient **infertile**. - It is an **overly aggressive** approach for stage 1a dysgerminoma in an adolescent girl, as the uterus is not involved, and fertility preservation is a crucial consideration.

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

Practice Questions

Radiation Therapy in Gynecologic Malignancies

Practice Questions

Chemotherapy in Gynecologic Oncology

Practice Questions

Palliative Care in Gynecologic Oncology

Practice Questions

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