Gynecologic Oncology — MCQs

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?

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Recurrence of hydatiform mole is assessed by:

Gynecologic Oncology Indian Medical PG Practice Questions and MCQs

Question 71: What is true about a hydatidiform mole?

A. Thyrotoxicosis is rare.
B. hCG levels are raised.
C. Hysterectomy is performed in selected cases.
D. All of the above. (Correct Answer)

Explanation: **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).

Question 72: Which of the following is not a germ cell tumor of the ovary?

A. Endodermal sinus tumor
B. Polyembryoma
C. Dysgerminoma
D. Brenner tumor (Correct Answer)

Explanation: 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.

Question 73: Most hereditary ovarian cancers result from germline mutations in which of the following genes?

A. BRCA1 and BRCA2 (Correct Answer)
B. MSH2
C. PMS1
D. MLH1

Explanation: **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.

Question 74: Which of the following is NOT a predisposing lesion for vulvar cancer?

A. Paget's disease
B. Lichen sclerosus
C. Vulvar intraepithelial neoplasia (VIN)
D. Familial cancer syndromes (Correct Answer)

Explanation: **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.

Question 75: Which of the following is the etiologic agent in a 70-year-old woman with squamous cell cancer of the vulva?

A. Lichen Sclerosus (Correct Answer)
B. Human Papillomavirus
C. Immunosuppression
D. Smoking

Explanation: **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).

Question 76: Pseudomyxoma peritonei is most commonly associated with which of the following ovarian tumors?

A. Serous cystadenoma
B. Pseudomucinous cyst
C. Mucinous cystadenoma (Correct Answer)
D. Teratoma

Explanation: **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.

Question 77: Acetic acid staining of the cervix shows the following findings EXCEPT:

A. Squamous metaplasia
B. Cervical carcinoma in situ
C. Cervical polyp (Correct Answer)
D. Cervical dysplasia

Explanation: **Explanation:** The application of 3-5% acetic acid to the cervix (Visual Inspection with Acetic Acid - VIA) is a screening tool used to identify pre-malignant and malignant lesions. The underlying principle is the **acetowhite reaction**, which occurs due to the dehydration of cells and the reversible coagulation of nuclear proteins. **Why Cervical Polyp is the correct answer:** A cervical polyp is typically a benign, pedunculated growth arising from the endocervical mucosa. It is highly vascular and covered by a thin layer of epithelium. Unlike dysplastic cells, polyps do not have a high nuclear-to-cytoplasmic (N/C) ratio or dense protein concentration. Therefore, they do not exhibit the characteristic opaque "acetowhite" change seen in neoplastic conditions. **Analysis of Incorrect Options:** * **Squamous Metaplasia:** This is a physiological process where columnar epithelium transforms into squamous epithelium. During the active phase, these cells have a slightly higher protein content and can show a faint, translucent, or "milky" acetowhite appearance, which is considered a normal finding. * **Cervical Carcinoma in situ (CIS) & Cervical Dysplasia (CIN):** These are neoplastic conditions characterized by increased cellularity and a high N/C ratio. The acetic acid cannot penetrate the dense nuclei, causing light to reflect off the surface, resulting in a distinct, opaque, and well-demarcated **acetowhite zone**. **High-Yield Clinical Pearls for NEET-PG:** * **VIA Positive:** Defined by the appearance of distinct, opaque, dense acetowhite areas with sharp margins near the squamocolumnar junction (SCJ). * **Schiller’s Test (Lugol’s Iodine):** Normal squamous cells contain glycogen and turn **mahogany brown**. Dysplastic cells are glycogen-deficient and remain **colorless/yellow** (Iodine negative). * **Acetowhite mimics:** Apart from dysplasia, acetowhite changes can also be seen in healing epithelium, inflammation, and HPV infection (condylomas).

Question 78: In a patient with suspected endometrial cancer, what is the optimal timing for an endometrial biopsy?

A. Day 9-10
B. Day 20-21
C. Day 26 (Correct Answer)
D. Day 2

Explanation: **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.

Question 79: 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?

A. Birth control pills
B. Caffeine consumption
C. Cigarette smoking
D. Family history (Correct Answer)

Explanation: **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 (<30 years). * **Note:** Early menarche (<12 years) and late menopause (>55 years) increase risk due to a longer "estrogen window."

Question 80: Recurrence of hydatiform mole is assessed by:

A. AFP level
B. b-HCG level (Correct Answer)
C. LDH level
D. Estrogen level

Explanation: **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.

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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