Gynecologic Oncology — MCQs

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 761: Most common cause of vulval carcinoma?

A. HPV infection (Correct Answer)
B. EBV infection
C. Herpes genitalis infection
D. Syphilis infection

Explanation: ***HPV infection*** - **Human Papillomavirus (HPV)**, particularly high-risk strains like HPV 16 and 18, is the most significant risk factor and cause of most vulvar squamous cell carcinomas. - HPV leads to **dysplastic changes** in the vulvar epithelium (vulvar intraepithelial neoplasia, VIN) that can progress to invasive cancer. *EBV infection* - **Epstein-Barr Virus (EBV)** is primarily associated with lymphomas (e.g., Burkitt lymphoma, Hodgkin lymphoma) and nasopharyngeal carcinoma, not vulvar carcinoma. - While EBV can cause various cancers, there is no direct link establishing it as a common cause of vulvar malignancy. *Herpes genitalis infection* - **Herpes Simplex Virus (HSV)** causes painful genital lesions but is not a recognized cause of vulvar carcinoma. - HSV infection is not associated with the cellular changes that lead to squamous cell cancer development. *Syphilis infection* - **Syphilis**, caused by *Treponema pallidum*, can lead to genital ulcers (chancres) and other systemic manifestations but is not a known cause of vulvar carcinoma. - While chronic inflammation is a risk factor for some cancers, syphilis does not directly induce the genetic mutations typical of vulvar cancer.

Question 762: What is the treatment for stage IB1 cervical cancer?

A. Chemotherapy
B. Radiation therapy
C. Chemoradiotherapy
D. Wertheim's hysterectomy (radical hysterectomy) (Correct Answer)

Explanation: ***Wertheim's hysterectomy (radical hysterectomy)*** - For **stage IB1** cervical cancer, **radical hysterectomy** (Type III/Wertheim's procedure) with pelvic lymphadenectomy is one of the two standard treatment options. - This procedure removes the uterus, cervix, parametrium, upper vagina, and pelvic lymph nodes to achieve clear margins and assess nodal involvement. - Preferred in **younger women** desiring to preserve ovarian function and sexual function, and in centers with surgical expertise. - Both radical surgery and chemoradiotherapy have **equivalent survival outcomes** for stage IB1. *Chemoradiotherapy* - **Definitive chemoradiotherapy** (concurrent cisplatin-based chemotherapy with external beam radiation plus brachytherapy) is the **other standard first-line treatment** for stage IB1 cervical cancer. - It is preferred in patients who are **poor surgical candidates**, have medical comorbidities, or prefer non-surgical management. - Also the treatment of choice for **locally advanced disease** (stages IB2, IIA2, IIB-IVA). *Radiation therapy* - **Radiation alone** (without concurrent chemotherapy) has inferior outcomes compared to chemoradiotherapy for stages IB1 and above. - May be used only in patients who cannot tolerate chemotherapy. *Chemotherapy* - **Chemotherapy alone** is not curative for localized cervical cancer. - Used for **recurrent or metastatic disease** (stage IVB) in combination with bevacizumab.

Question 763: Extramammary Paget's disease of the vulva is most commonly associated with which other cancer?

A. Vulvar cancer (Correct Answer)
B. Vaginal cancer
C. Cervical cancer
D. Uterine cancer

Explanation: ***Vulvar cancer*** - **Extramammary Paget's disease (EMPD)** frequently presents in the vulvar region and is associated with an underlying **adenocarcinoma** in up to 30% of cases. - The disease involves intraepithelial adenocarcinoma cells that can spread locally and, in some instances, indicates a synchronous or metachronous **internal malignancy**, often of genitourinary or gastrointestinal origin, but primarily vulvar adenocarcinoma in this context. *Vaginal cancer* - While Paget's disease can occur in other anogenital areas, its association with **primary vaginal cancer** is much less common compared to vulvar involvement. - **Vaginal Paget's disease** is rare and usually represents secondary spread from a vulvar primary or an underlying bladder/urethral carcinoma. *Cervical cancer* - **Paget's disease** is not typically associated with **cervical cancer**. Cervical cancers are predominantly squamous cell carcinomas or adenocarcinomas arising from the transformation zone. - While cervical adenocarcinoma can present with similar cells to Paget's, it is a distinct entity and not a common association. *Uterine cancer* - **Uterine cancer**, primarily endometrial carcinoma, has no direct or common association with **Paget's disease**. - Paget's disease primarily affects the skin and can be associated with underlying gland cancers, but these are generally in proximity to the epidermal involvement rather than distant uterine sites.

Question 764: Poor prognostic factor for hydatidiform mole is -

A. Prior molar pregnancy
B. Metastasis to lung
C. No prior chemotherapy
D. WHO score > 8 (Correct Answer)

Explanation: ***WHO score > 8*** - A **WHO score > 8** (more specifically, WHO/FIGO score ≥7) indicates **high-risk gestational trophoblastic neoplasia (GTN)**, which is associated with a poor prognosis and requires multi-agent chemotherapy. - The WHO prognostic scoring system incorporates various factors: age, prior pregnancy outcome, antecedent pregnancy type, interval from index pregnancy, pre-treatment hCG level, largest tumor size, site of metastases, and number of metastases. - This is the **strongest poor prognostic indicator** among the options listed. *Prior molar pregnancy* - A **prior molar pregnancy** increases the *risk* of developing another molar pregnancy (recurrence risk ~1-2%), but it is **not a component of the WHO prognostic scoring system** and is not a poor prognostic factor for the outcome of current GTN. - The history affects surveillance requirements but doesn't dictate the difficulty of treating the current episode. *Metastasis to lung* - **Lung metastases** are actually among the **better prognostic sites** for metastatic GTN in the WHO scoring system. - Lung and vaginal metastases score only 1 point, whereas liver and brain metastases (true poor prognostic sites) score 4 points each. - While any metastasis indicates more advanced disease, isolated lung metastases generally have a *good prognosis* with appropriate chemotherapy, with cure rates >90%. *No prior chemotherapy* - The *absence* of **prior chemotherapy** is a **favorable prognostic factor**, not a poor one. - Patients who have *failed* prior chemotherapy or have received ≥2 drugs previously score 2-4 points in the WHO system, indicating worse prognosis. - No prior chemotherapy (scores 0 points) means better treatment response and outcomes.

Question 765: What is the most common cause of death in cervical cancer?

A. Infection
B. Haemorrhage
C. Metastasis to vital organs
D. Renal failure (Correct Answer)

Explanation: ***Renal failure*** - As cervical cancer progresses, it can invade surrounding structures, including the **ureters**. - **Ureteral obstruction** leads to **hydronephrosis** and ultimately **renal failure**, which is a common cause of death. *Infection* - While infections can occur due to immunosuppression or compromised tissue integrity in advanced cancer, they are generally **not the most common direct cause of death**. - Infections are often secondary complications rather than the primary mode of mortality. *Haemorrhage* - Local invasion of blood vessels by advanced cervical cancer can cause **significant bleeding** (haemorrhage). - While potentially life-threatening, it is **less frequent** as a direct cause of death compared to renal failure. *Metastasis to vital organs* - Cervical cancer can metastasize to distant organs like the lungs, liver, or bone; however, direct organ failure solely due to metastases is **less common than renal complications** from local tumor spread. - The impact of metastases often contributes to overall decline but is not the most frequent immediate cause of death.

Question 766: Which of the following is the PRIMARY risk factor for cervical carcinoma?

A. Human papilloma virus (Correct Answer)
B. Smoking
C. Low socioeconomic status
D. All of the options

Explanation: ***Human papilloma virus*** - **High-risk HPV types**, particularly **HPV 16 and 18**, are the primary causative agent of cervical carcinoma, responsible for over 90% of cases. - HPV infection is the **most significant and essential risk factor**, leading to persistent changes in cervical cells that can progress to **dysplasia** and eventually **invasive cancer**. - Cervical cancer is considered an **HPV-associated malignancy**, making HPV the central etiological factor. *Smoking* - **Smoking** is an important cofactor that increases the risk of cervical carcinoma in women with HPV infection, but it is not the primary cause. - Smoking impairs the immune system's ability to clear HPV infections and promotes progression of HPV-induced lesions. - Without HPV infection, smoking alone does not cause cervical cancer. *Low socioeconomic status* - **Low socioeconomic status** is an indirect risk factor associated with reduced access to healthcare and **cervical cancer screening** (Pap smears). - It does not directly cause cervical cancer but leads to delayed diagnosis and treatment, resulting in poorer outcomes. *All of the options* - While all listed factors influence cervical carcinoma risk, **Human papillomavirus (HPV)** is the primary and essential causative agent. - The other factors are cofactors or indirect associations, not primary causes.

Question 767: A patient presents with bilateral ovarian carcinoma, capsule involvement, ascites, and paraaortic lymphadenopathy. What is the appropriate stage of the disease?

A. Stage 1C
B. Stage 3C (Correct Answer)
C. Stage 2C
D. Stage 4C

Explanation: ***Stage 3C*** - **Bilateral ovarian carcinoma** with **capsule involvement**, **ascites**, and especially **paraaortic lymph node metastases** are defining features of Stage IIIC ovarian cancer. - Involvement of **retroperitoneal lymph nodes**, including paraaortic nodes, automatically upstages the disease to Stage III, irrespective of other abdominal spread. *Stage 1C* - This stage refers to ovarian cancer confined to **one or both ovaries**, with evidence of rupture, capsule involvement, or malignant cells in ascites/peritoneal washings, but **without lymph node involvement**. - The presence of **paraaortic lymphadenopathy** in this patient immediately excludes Stage 1C. *Stage 2C* - Stage 2 ovarian cancer involves one or both ovaries with **pelvic extension** beyond the ovaries, but still **without lymph node involvement**. - The patient's involvement of **paraaortic lymph nodes** goes beyond pelvic extension and therefore excludes Stage 2C. *Stage 4C* - Stage 4 ovarian carcinoma involves **distant metastasis** beyond the peritoneal cavity or distant lymph nodes (e.g., pleural effusion with positive cytology, parenchymal liver/spleen metastasis). - While paraaortic lymphadenopathy indicates advanced disease, it falls within the criteria for Stage 3 due to its location, not Stage 4.

Question 768: Most common presentation of cervical cancer is -

A. Abnormal vaginal bleeding (Correct Answer)
B. Pelvic pain
C. Pain during intercourse
D. Unusual vaginal discharge

Explanation: ***Abnormal vaginal bleeding*** - **Abnormal vaginal bleeding** is the most frequent presenting symptom of cervical cancer, often manifesting as **postcoital bleeding**, intermenstrual bleeding, or heavier, longer menstrual periods. - This symptom arises as the tumor on the cervix ulcerates and bleeds due to its friable nature and rich vascularization. *Pelvic pain* - **Pelvic pain** is typically a symptom of more **advanced cervical cancer**, indicating tumor invasion into surrounding tissues or nerves. - It is not usually an early or the most common presenting symptom, unlike abnormal bleeding. *Pain during intercourse* - **Pain during intercourse (dyspareunia)** can be a symptom of cervical cancer, particularly with larger lesions or those causing inflammation. - However, it is less common than abnormal bleeding and often occurs concurrently with or after the onset of bleeding symptoms. *Unusual vaginal discharge* - An **unusual vaginal discharge**, which may be watery, foul-smelling, or blood-tinged, can occur with cervical cancer. - While a common symptom, it is generally considered less frequent than abnormal vaginal bleeding as the primary presenting complaint.

Question 769: In which stage of cervical carcinoma is surgery performed to retain the possibility of conception?

A. Stage 1B1 (Correct Answer)
B. Stage 1B2
C. Stage 2A
D. Stage 2B

Explanation: ***Stage 1B1*** - In **Stage 1B1 cervical carcinoma** (FIGO 2018), the tumor size is **≤2 cm** and confined to the cervix, making it amenable to **fertility-sparing surgery** like radical trachelectomy. - This stage allows for removal of the cervix and parametrium while preserving the **uterine body** and ovaries, thus retaining the possibility of conception. - Strict selection criteria must be met including tumor size ≤2 cm, no lymphovascular space invasion, negative lymph nodes, and adequate follow-up compliance. *Stage 1B2* - **Stage 1B2** (FIGO 2018) involves tumors **>2 cm to ≤4 cm** but still confined to the cervix, which generally have a higher risk of recurrence and lymph node metastasis. - While fertility-sparing surgery might be considered in highly selective cases with tumors 2-3 cm, it is much less commonly performed than in Stage 1B1 due to the increased tumor burden and higher oncological risk. *Stage 2A* - In **Stage 2A cervical carcinoma**, the tumor has spread beyond the cervix to involve the upper two-thirds of the vagina (2A1: ≤4 cm, 2A2: >4 cm) but not the parametrium. - The disease extent typically necessitates more aggressive treatment such as radical hysterectomy or **chemoradiation**, precluding preservation of fertility in most cases. *Stage 2B* - **Stage 2B** involves tumor invasion into the **parametrium**, making fertility-sparing surgery contraindicated and typically requiring **definitive chemoradiation**. - The spread of cancer to the parametrium indicates a more advanced disease that cannot be adequately treated by methods that preserve fertility.

Question 770: Which of the following statements about radical hysterectomy in stage Ib cervical cancer compared to radiotherapy is false?

A. Chance of recurrence is lower with radical hysterectomy.
B. Ovarian function can be preserved.
C. Chance of survival is higher with radical hysterectomy.
D. It is less complicated than radiotherapy. (Correct Answer)

Explanation: ***It is less complicated than radiotherapy.*** - Radical hysterectomy is a **major surgical procedure** with potential complications like **hemorrhage**, infection, **ureteral injury**, and **lymphedema**, which can be significant and life-altering. - Radiotherapy, while having its own set of side effects (e.g., **vaginal stenosis**, bladder/rectal irritation), typically avoids the acute surgical risks and recovery period associated with extensive surgery. *Chance of recurrence is lower with radical hysterectomy.* - For early-stage cervical cancer (Ib1/Ib2), both **radical hysterectomy** and **radiotherapy** provide **comparable outcomes** in terms of recurrence rates. - The choice between therapies often depends on patient factors, surgeon expertise, and pathological findings, but neither consistently demonstrates a significantly lower recurrence rate over the other in large cohorts. *Ovarian function can be preserved.* - In younger patients undergoing **radical hysterectomy**, it is often possible to **preserve the ovaries** by transplanting them or avoiding their removal if not directly involved, thus maintaining **endocrine function**. - **Pelvic radiotherapy**, in contrast, invariably leads to **ovarian radiation** and subsequent **ovarian failure** and menopause. *Chance of survival is higher with radical hysterectomy.* - For early-stage cervical cancer (Ib), **overall survival rates** are generally **equivalent** between radical hysterectomy and primary radiotherapy. - Meta-analyses and large retrospective studies have shown **similar 5-year survival rates** for both treatment modalities when applied appropriately to well-selected patients.

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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