Gynecologic Oncology Practice Questions

Q: What is true about a hydatidiform mole?

All of the above.. **Explanation:** Hydatidiform mole (molar pregnancy) is a gestational trophoblastic disease characterized by the abnormal proliferation of trophoblastic tissue. 1. **hCG levels are raised (Option B):** This is the hallmark of molar pregnancy. The hyperplastic trophoblastic cells secrete excessive amounts of human chorionic gonadotropin (hCG), often exceeding 100,000 mIU/mL. This leads to the classic "snowstorm appearance" on ultrasound and exaggerated pregnancy symptoms. 2. **Thyrotoxicosis is rare (Option A):** While hCG shares a common alpha-subunit with Thyroid Stimulating Hormone (TSH), it can weakly bind to TSH receptors. Although biochemical hyperthyroidism (low TSH, high T4) is common in moles, **clinically evident thyrotoxicosis** is actually rare, occurring in less than 5% of cases. 3. **Hysterectomy in selected cases (Option C):** While suction evacuation is the standard treatment, hysterectomy is an option for women who have completed their childbearing and are at high risk for post-molar gestational trophoblastic neoplasia (GTN), particularly those over age 40. Since all three statements are clinically accurate, **Option D (All of the above)** is the correct answer. **High-Yield NEET-PG Pearls:** * **Most common site of metastasis:** Lungs (followed by vagina). * **Theca Lutein Cysts:** Occur in 25-30% of cases due to high hCG levels; they usually regress spontaneously after evacuation. * **Follow-up:** Weekly hCG monitoring until three consecutive negative results, then monthly for 6 months. * **Karyotype:** Complete Mole is 46,XX (diploid, paternal origin); Partial Mole is 69,XXX/XXY (triploid).

Q: Which of the following is not a germ cell tumor of the ovary?

Brenner tumor. To answer this question correctly, one must understand the histological classification of ovarian tumors, which are categorized based on their tissue of origin: **Surface Epithelial**, **Germ Cell**, and **Sex Cord-Stromal** tumors. ### **Why Brenner Tumor is the Correct Answer** The **Brenner tumor** is a **Surface Epithelial-Stromal tumor**, not a germ cell tumor. It is characterized histologically by "Walthard cell nests"—islands of transitional epithelium (resembling bladder epithelium) within a dense fibromatous stroma. On microscopy, the nuclei often show a longitudinal groove, famously described as **"Coffee-bean nuclei."** Most Brenner tumors are benign and are often incidental findings. ### **Analysis of Incorrect Options (Germ Cell Tumors)** Germ cell tumors (GCTs) arise from the primordial germ cells of the ovary and typically occur in young women (ages 10–30). * **Dysgerminoma (Option C):** The most common malignant GCT. It is the female counterpart of the testicular seminoma. It is highly radiosensitive and associated with elevated **LDH**. * **Endodermal Sinus Tumor (Option A):** Also known as Yolk Sac Tumor. It is highly aggressive and characterized by **Schiller-Duval bodies** on histology and elevated **Alpha-fetoprotein (AFP)**. * **Polyembryoma (Option B):** An extremely rare and highly malignant GCT composed of "embryoid bodies" that resemble early embryos. ### **High-Yield Clinical Pearls for NEET-PG** * **Most common ovarian tumor overall:** Serous Cystadenoma (Epithelial). * **Most common germ cell tumor:** Benign Cystic Teratoma (Dermoid cyst). * **Tumor Markers:** * Dysgerminoma → LDH, hCG. * Yolk Sac Tumor → AFP. * Choriocarcinoma → β-hCG. * **Brenner Tumor Association:** Often associated with mucinous cystadenomas; look for the "Coffee-bean nuclei" keyword in clinical vignettes.

Q: Most hereditary ovarian cancers result from germline mutations in which of the following genes?

BRCA1 and BRCA2. **Explanation:** **1. Why BRCA1 and BRCA2 are correct:** Approximately 10–15% of epithelial ovarian cancers are hereditary. The vast majority (about 90%) of these hereditary cases are attributed to **Hereditary Breast and Ovarian Cancer (HBOC) syndrome**, which is caused by germline mutations in the **BRCA1 and BRCA2** genes. These are tumor suppressor genes involved in DNA repair via homologous recombination. * **BRCA1** mutation carries a cumulative lifetime risk of ovarian cancer of approximately **40–50%**. * **BRCA2** mutation carries a lifetime risk of approximately **15–25%**. **2. Why other options are incorrect:** * **MSH2, MLH1, and PMS1 (Options B, C, D):** These are DNA mismatch repair (MMR) genes. Mutations in these genes cause **Lynch Syndrome** (Hereditary Non-Polyposis Colorectal Cancer - HNPCC). While Lynch syndrome is the second most common cause of hereditary ovarian cancer, it accounts for only about 10–15% of hereditary cases (much less than BRCA). In Lynch syndrome, the risk of endometrial cancer is significantly higher than the risk of ovarian cancer. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** BRCA-associated ovarian cancers are typically **High-Grade Serous Carcinomas (HGSC)**. * **Prognosis:** Interestingly, BRCA-mutated ovarian cancers often have a *better* prognosis and better response to platinum-based chemotherapy and PARP inhibitors (e.g., Olaparib) compared to sporadic cases. * **Prophylaxis:** Risk-reducing salpingo-oophorectomy (RRSO) is recommended by age 35–40 for BRCA1 and age 40–45 for BRCA2 carriers. * **Lynch Syndrome Triad:** Increased risk of Colorectal, Endometrial, and Ovarian cancers.

Q: Which of the following is NOT a predisposing lesion for vulvar cancer?

Familial cancer syndromes. **Explanation:** Vulvar cancer is primarily a disease of elderly women, arising through two distinct pathogenic pathways. The correct answer is **Familial cancer syndromes** because, unlike breast, ovarian, or colon cancers (e.g., BRCA or Lynch Syndrome), vulvar cancer does not have a recognized hereditary or familial genetic predisposition. It is almost exclusively associated with localized chronic irritation or viral infection. **Analysis of Options:** * **Lichen sclerosus:** This is the most common precursor for the **HPV-independent pathway**. It typically affects postmenopausal women. Chronic inflammation leads to "differentiated VIN" (dVIN), which carries a high risk of progression to keratinizing squamous cell carcinoma. * **Vulvar Intraepithelial Neoplasia (VIN):** This is the classic precursor lesion. **Usual-type VIN** (uVIN) is associated with high-risk HPV types (16, 18) and is common in younger, smoking women. **Differentiated VIN** (dVIN) is associated with Lichen sclerosus. * **Paget’s Disease:** Extramammary Paget’s disease of the vulva is a preinvasive intraepithelial neoplasia. While often confined to the epithelium, it is associated with an underlying invasive vulvar adenocarcinoma in about 10–15% of cases. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous cell carcinoma (90%). * **Most common site:** Labia majora. * **Staging:** Vulvar cancer is staged **surgically** (FIGO). * **Lymphatic Spread:** The sentinel lymph nodes are the **Inguinal nodes** (specifically the superficial inguinal nodes). The "Cloquet’s node" is the highest deep inguinal node and signifies spread to pelvic nodes. * **Risk Factors:** Smoking, HPV 16/18, immunosuppression, and chronic vulvar dystrophies.

Q: Which of the following is the etiologic agent in a 70-year-old woman with squamous cell cancer of the vulva?

Lichen Sclerosus. **Explanation:** Squamous cell carcinoma (SCC) of the vulva follows two distinct pathogenic pathways. In an **elderly patient (typically >65–70 years)**, the cancer usually arises from a background of chronic inflammatory conditions, most notably **Lichen Sclerosus** or differentiated Vulvar Intraepithelial Neoplasia (dVIN). This "keratinizing" type of SCC is independent of HPV infection and is often associated with TP53 mutations. **Analysis of Options:** * **A. Lichen Sclerosus (Correct):** This is the most common precursor in older women. Long-standing inflammation leads to cellular atypia and progression to SCC. It presents as "parchment-like" or "cigarette paper" skin. * **B. Human Papillomavirus (HPV):** This is the etiology for the second pathway, typically seen in **younger women (35–55 years)**. It is associated with high-risk strains (HPV 16, 18) and "warty" or "basaloid" Vulvar Intraepithelial Neoplasia (uVIN). * **C & D. Immunosuppression and Smoking:** While these are significant risk factors for HPV-related vulvar and cervical cancers (by hindering viral clearance), they are not the primary etiologic agents for the keratinizing SCC seen in a 70-year-old. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of Vulvar Cancer:** Squamous Cell Carcinoma (90%). * **Most common site:** Labia majora. * **Precursor lesions:** * Elderly = Lichen Sclerosus $\rightarrow$ dVIN (TP53 mutation). * Younger = HPV $\rightarrow$ uVIN (p16 positive). * **Lymphatic Spread:** The primary route of spread is to the **Inguinal-femoral lymph nodes** (Sentinel node biopsy is the standard for early-stage disease).

Q: Pseudomyxoma peritonei is most commonly associated with which of the following ovarian tumors?

Mucinous cystadenoma. **Explanation:** **Pseudomyxoma peritonei (PMP)** is a clinical condition characterized by the accumulation of abundant gelatinous (mucinous) fluid within the peritoneal cavity, often referred to as "jelly belly." **Why Mucinous Cystadenoma is correct:** The condition occurs when a mucin-producing tumor ruptures or leaks cells into the peritoneum. In gynecology, **Mucinous cystadenoma** (or its borderline variant) is the most common ovarian tumor associated with PMP. These tumors are lined by tall columnar epithelium that secretes thick, viscid mucin. When these cells implant on the peritoneal surface, they continue to produce mucin, leading to massive abdominal distension. **Analysis of Incorrect Options:** * **Serous cystadenoma:** These are the most common epithelial tumors but contain thin, watery fluid. They are associated with Psammoma bodies, not PMP. * **Pseudomucinous cyst:** This is an older, less precise term for mucinous tumors. "Mucinous cystadenoma" is the standard pathological diagnosis. * **Teratoma:** While mature cystic teratomas (dermoid cysts) can contain various tissues (hair, sebum, teeth), they do not typically produce the diffuse mucinous implants characteristic of PMP. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Source:** While often associated with the ovary in older texts, modern pathology shows that the **Appendix** (Mucocele or Appendiceal Adenocarcinoma) is the most common primary site for PMP. * **The "Sister Mary Joseph Nodule":** Can sometimes be seen in advanced cases where the tumor metastasizes to the umbilicus. * **Treatment:** The gold standard is **Cytoreductive Surgery (CRS)** combined with **Hyperthermic Intraperitoneal Chemotherapy (HIPEC)**. * **Ovarian Link:** If PMP is found with an ovarian mass, always check the appendix, as the ovarian involvement is often secondary.

Q: In a patient with suspected endometrial cancer, what is the optimal timing for an endometrial biopsy?

Day 26. **Explanation:** In the context of evaluating endometrial pathology, particularly when investigating abnormal uterine bleeding (AUB) or suspected malignancy, the timing of the biopsy is crucial for accurate histological interpretation. **Why Day 26 is Correct:** The optimal time for an endometrial biopsy is during the **late secretory phase (Day 26 of a 28-day cycle)**. At this stage, the endometrium is at its maximum thickness and reflects the cumulative effect of progesterone. This timing is ideal for two reasons: 1. **Detection of Hyperplasia/Malignancy:** It provides the most tissue volume for sampling, making it easier to identify architectural abnormalities or cellular atypia. 2. **Assessment of Luteal Function:** Historically, this timing was used to diagnose Luteal Phase Deficiency (LPD) by checking if the histological dating lags behind the menstrual date by more than 2 days. **Analysis of Incorrect Options:** * **Day 2 & Day 9-10 (Options D & A):** These represent the menstrual and early proliferative phases. The endometrium is thin and denuded, providing insufficient tissue for a reliable diagnosis of cancer or hyperplasia. * **Day 20-21 (Option B):** This is the mid-secretory phase (the "implantation window"). While the endometrium is secretory, it has not yet reached the full development seen in the late secretory phase. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** While Pipelle biopsy is the initial investigation of choice for suspected endometrial cancer (sensitivity >90%), **Fractional Curettage (D&C)** remains the gold standard for definitive diagnosis. * **Postmenopausal Bleeding:** In postmenopausal women, timing is irrelevant. Any endometrial thickness **>4 mm** on TVS necessitates a biopsy. * **Most Common Type:** Endometrioid adenocarcinoma is the most common histological subtype of endometrial cancer.

Q: A 40-year-old woman has the following family and personal history: her mother died of breast cancer at age 64, she smokes one pack per day, she drinks five or more cups of coffee per day, she has no children, and she takes birth control pills. Which of the following is the most significant risk factor for breast cancer in this patient?

Family history. **Explanation:** **1. Why Family History is Correct:** Family history is one of the most significant non-modifiable risk factors for breast cancer. Having a first-degree relative (mother, sister, or daughter) with breast cancer approximately **doubles a woman's risk**. While the mother in this case was diagnosed at age 64 (postmenopausal), the presence of a first-degree relative remains the most potent risk factor among the choices provided. In clinical practice, risk assessment tools (like the Gail Model) heavily weight family history over lifestyle factors. **2. Why the Other Options are Incorrect:** * **Birth Control Pills (OCPs):** While some studies suggest a very slight, transient increase in breast cancer risk during active use, this risk is considered minimal and returns to baseline 10 years after discontinuation. Conversely, OCPs are highly protective against ovarian and endometrial cancers. * **Caffeine Consumption:** There is no established causal link between caffeine intake and an increased risk of breast cancer. In fact, some studies suggest caffeine may have a neutral or slightly protective effect. * **Cigarette Smoking:** While smoking is a major risk factor for many malignancies (lung, bladder, cervix), its direct link to breast cancer is less definitive compared to family history, though it may increase risk in specific subgroups (e.g., premenopausal women). **3. NEET-PG High-Yield Pearls:** * **Most significant risk factor overall:** Increasing age. * **Most significant genetic factor:** BRCA1 (60-80% lifetime risk) and BRCA2 mutations. * **Modifiable risk factors:** Obesity (postmenopausal), alcohol consumption, and nulliparity (increased estrogen exposure). * **Protective factors:** Breastfeeding, physical activity, and early pregnancy ( 55 years) increase risk due to a longer "estrogen window."

Q: Recurrence of hydatiform mole is assessed by:

b-HCG level. **Explanation:** **Why b-HCG is the correct answer:** Hydatidiform mole is a type of Gestational Trophoblastic Disease (GTD) arising from the abnormal proliferation of trophoblastic tissue (syncytiotrophoblast and cytotrophoblast). These trophoblastic cells naturally secrete **beta-human chorionic gonadotropin (b-HCG)**. Because b-HCG has a direct correlation with the tumor burden, it serves as an ideal **tumor marker** for diagnosis, monitoring the success of evacuation, and detecting recurrence or progression into Gestational Trophoblastic Neoplasia (GTN). After evacuation, b-HCG levels should ideally fall to undetectable levels; any plateau or rise indicates persistent disease or recurrence. **Why the other options are incorrect:** * **A. AFP (Alpha-fetoprotein):** This is a marker for yolk sac tumors, hepatocellular carcinoma, and neural tube defects. It is not produced by trophoblastic tissue. * **C. LDH (Lactate Dehydrogenase):** While elevated in several malignancies (like dysgerminomas or lymphomas) due to high cell turnover, it is non-specific and not used to monitor molar recurrence. * **D. Estrogen level:** While estrogen levels may be elevated during pregnancy, they do not accurately reflect trophoblastic mass or activity and lack the sensitivity required for oncological follow-up. **High-Yield Clinical Pearls for NEET-PG:** * **Follow-up Protocol:** After evacuation, b-HCG should be monitored **weekly** until three consecutive negative results are obtained, then **monthly** for 6 months. * **Contraception:** Patients must use reliable contraception (preferably OCPs) during the follow-up period to ensure a new pregnancy does not mask a rising b-HCG level from recurrence. * **Half-life:** The initial half-life of b-HCG after evacuation is approximately 24–36 hours. * **Snowstorm Appearance:** The classic ultrasound finding for a complete hydatidiform mole.

Question 1

What is true about a hydatidiform mole?

Accepted Answer

All of the above.

Answer

Thyrotoxicosis is rare.

Answer

hCG levels are raised.

Answer

Hysterectomy is performed in selected cases.

Question 2

Which of the following is not a germ cell tumor of the ovary?

Accepted Answer

Brenner tumor

Answer

Endodermal sinus tumor

Answer

Polyembryoma

Answer

Dysgerminoma

Question 3

Most hereditary ovarian cancers result from germline mutations in which of the following genes?

Accepted Answer

BRCA1 and BRCA2

Answer

MSH2

Answer

PMS1

Answer

MLH1

Question 4

Which of the following is NOT a predisposing lesion for vulvar cancer?

Accepted Answer

Familial cancer syndromes

Answer

Paget's disease

Answer

Lichen sclerosus

Answer

Vulvar intraepithelial neoplasia (VIN)

Question 5

Which of the following is the etiologic agent in a 70-year-old woman with squamous cell cancer of the vulva?

Accepted Answer

Lichen Sclerosus

Answer

Human Papillomavirus

Answer

Immunosuppression

Answer

Smoking

Question 6

Pseudomyxoma peritonei is most commonly associated with which of the following ovarian tumors?

Accepted Answer

Mucinous cystadenoma

Answer

Serous cystadenoma

Answer

Pseudomucinous cyst

Answer

Teratoma

Question 7

Acetic acid staining of the cervix shows the following findings EXCEPT:

Accepted Answer

Cervical polyp

Answer

Squamous metaplasia

Answer

Cervical carcinoma in situ

Answer

Cervical dysplasia

Question 8

In a patient with suspected endometrial cancer, what is the optimal timing for an endometrial biopsy?

Accepted Answer

Day 26

Answer

Day 9-10

Answer

Day 20-21

Answer

Day 2

Question 9

A 40-year-old woman has the following family and personal history: her mother died of breast cancer at age 64, she smokes one pack per day, she drinks five or more cups of coffee per day, she has no children, and she takes birth control pills. Which of the following is the most significant risk factor for breast cancer in this patient?

Accepted Answer

Family history

Answer

Birth control pills

Answer

Caffeine consumption

Answer

Cigarette smoking

Question 10

Recurrence of hydatiform mole is assessed by:

Accepted Answer

b-HCG level

Answer

AFP level

Answer

LDH level

Answer

Estrogen level

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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