Gynecologic Oncology Practice Questions

Q: What is the stage of an ovarian tumor if only one ovary is involved, without surface involvement or rupture?

Stage IA. **Explanation:** The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics)** classification. This question tests the specific criteria for Stage I, where the tumor is strictly limited to the ovaries or fallopian tubes. **Why Stage IA is correct:** * **Stage IA** is defined as a tumor limited to **one ovary** (capsule intact) or one fallopian tube. * Crucially, there must be **no tumor on the external surface**, no rupture of the capsule, and no malignant cells in the ascites or peritoneal washings. **Why the other options are incorrect:** * **Stage IB:** The tumor involves **both ovaries** or fallopian tubes, but the capsules are still intact, and there is no surface involvement or malignant cells in washings. * **Stage IC:** The tumor is limited to one or both ovaries/tubes but with specific complications: * **Stage IC1:** Surgical spill (intraoperative rupture). * **Stage IC2:** Capsule ruptured **before surgery** or tumor present on the ovarian/tubal surface. * **Stage IC3:** Malignant cells present in the ascites or peritoneal washings. **High-Yield NEET-PG Pearls:** 1. **Most common type:** Epithelial Ovarian Cancer (Serous is the most frequent subtype). 2. **Staging Method:** Ovarian cancer is **surgically staged**. 3. **Prognostic Factor:** The integrity of the capsule (Stage IA vs. IC) is a major prognostic factor and determines the need for adjuvant chemotherapy. 4. **CA-125:** While used for monitoring, it is not part of the FIGO staging criteria.

Q: CA 125 is primarily used for which of the following purposes?

Follow-up monitoring of ovarian cancer. **Explanation:** **CA 125 (Cancer Antigen 125)** is a high-molecular-weight glycoprotein produced by derivatives of the coelomic epithelium (pleura, pericardium, peritoneum) and the Müllerian epithelium (fallopian tube, endometrium, endocervix). **1. Why Option A is correct:** The primary clinical utility of CA 125 is the **monitoring of treatment response** and the **detection of recurrence** in patients with epithelial ovarian cancer (EOC). A decrease in levels indicates a positive response to chemotherapy or surgery, while a rising trend often precedes clinical or radiological evidence of recurrence by months. **2. Why other options are incorrect:** * **Option D (Diagnosis of Ovarian Cancer):** CA 125 is **not** a screening or definitive diagnostic tool for the general population because it lacks specificity. It is elevated in only 50% of Stage I cases and can be falsely elevated in numerous benign conditions (Endometriosis, PID, Fibroids, Pregnancy, Menstruation). * **Options B & C (Pancreatic/Stomach Cancer):** While CA 125 can be elevated in various intra-abdominal malignancies due to peritoneal irritation, it is not the marker of choice. **CA 19-9** is the primary marker for pancreatic and hepatobiliary cancers, while **CEA** is more relevant for GI malignancies. **Clinical Pearls for NEET-PG:** * **Cut-off value:** Normal is generally **<35 U/mL**. * **Post-menopausal utility:** A high CA 125 in a post-menopausal woman with an adnexal mass is highly suspicious of malignancy (high positive predictive value). * **Mucinous Tumors:** CA 125 is often normal; **CEA** and **CA 19-9** are more likely to be elevated. * **Germ Cell Tumors:** Remember other markers—**LDH** (Dysgerminoma), **AFP** (Yolk sac tumor), and **hCG** (Choriocarcinoma).

Q: A 35-year-old female presents with postcoital bleeding. What is the next appropriate step in management?

Pap smear along with clinical examination. **Explanation:** The primary concern in a patient presenting with **postcoital bleeding** is to rule out **Cervical Cancer**. In a 35-year-old woman, the initial management must involve a systematic approach to visualize the cervix and obtain a cytological sample. **Why Option A is Correct:** The standard protocol for any woman presenting with postcoital bleeding is a **Triple Assessment** approach: 1. **Clinical Examination:** A per-speculum (P/S) examination is vital to visualize the cervix for any gross lesions, polyps, or friability. 2. **Cytology (Pap Smear):** To screen for pre-malignant (CIN) or malignant changes. 3. **Digital Examination:** To assess the consistency and size of the cervix. Even if the Pap smear is negative, a suspicious-looking cervix on clinical examination warrants a biopsy. **Why Other Options are Incorrect:** * **Options B & C (VIA/VILI):** Visual Inspection with Acetic Acid (VIA) and Lugol’s Iodine (VILI) are primarily used as **screening tools in low-resource settings** where cytology is unavailable. They are not the definitive next step in a diagnostic workup for a symptomatic patient in a clinical setting. * **Option D (Colposcopy-directed biopsy):** This is a secondary investigation. It is indicated only if the Pap smear shows abnormalities (e.g., HSIL, LSIL) or if there is a **clinically suspicious lesion** seen during the initial examination. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause** of postcoital bleeding in India: **Cervical Cancer** (until proven otherwise). * **Most common benign cause**: Cervical ectropion or cervical polyps. * If a **gross growth** is visible on the cervix during the initial examination, do not wait for a Pap smear; proceed directly to a **punch biopsy**. * Postcoital bleeding is a "red flag" symptom that bypasses routine screening intervals.

Q: A 55-year-old lady presents with postmenopausal bleeding for 3 months and a 1 x 1 cm nodule on the anterior lip of the cervix. What is the most appropriate investigation to be done subsequently?

Punch biopsy. **Explanation:** The clinical presentation of a **visible growth or nodule** on the cervix, especially in a postmenopausal woman with bleeding, is highly suspicious for cervical malignancy until proven otherwise. **1. Why Punch Biopsy is the Correct Answer:** Whenever a **grossly visible lesion** is present on the cervix, the immediate next step is a **punch biopsy**. The primary goal is to obtain a tissue diagnosis to confirm or rule out invasive carcinoma. In the presence of a visible growth, screening or diagnostic aids like Pap smears or colposcopy are bypassed in favor of a definitive histological diagnosis. **2. Why Other Options are Incorrect:** * **A. Pap smear:** This is a screening tool for asymptomatic women or those with a normal-looking cervix. In the presence of a visible lesion, a Pap smear has a high false-negative rate (up to 20%) and should not delay a definitive biopsy. * **C. Endocervical curettage (ECC):** This is indicated when the transformation zone is not fully visible on colposcopy or to evaluate the endocervical canal. It is not the primary investigation for an ectocervical nodule. * **D. Colposcopy:** This is used to identify "suspicious areas" in patients with abnormal Pap smears but a clinically normal-looking cervix. Since the lesion is already visible to the naked eye, colposcopy is unnecessary for localization; direct biopsy is indicated. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Never perform a Pap smear on a visible growth; always perform a biopsy. * **Postmenopausal Bleeding:** While the most common cause is atrophic vaginitis, the most important cause to rule out is malignancy (Endometrial > Cervical). * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), and a biopsy is the first step in that diagnostic pathway.

Q: Which of the following is a cause of post-menopausal bleeding?

Granulosa cell tumor. **Explanation:** Post-menopausal bleeding (PMB) is most commonly caused by atrophic changes, but when associated with ovarian pathology, it is typically due to **estrogen-secreting tumors**. **Why Granulosa Cell Tumor is Correct:** Granulosa cell tumors (GCT) are the most common type of **Sex Cord-Stromal Tumors**. They are functionally active and primarily secrete **estrogen**. In post-menopausal women, this excess estrogen causes endometrial hyperplasia, which often manifests as abnormal uterine bleeding or PMB. GCTs are considered tumors of "low malignant potential" and are characterized histologically by **Call-Exner bodies** and "coffee-bean" nuclei. **Analysis of Incorrect Options:** * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** These are androgen-secreting tumors. They cause virilization (hirsutism, clitoromegaly) and amenorrhea rather than post-menopausal bleeding. * **Cystadenoma (Serous/Mucinous):** These are common epithelial tumors. They are generally non-functional (do not produce hormones) and typically present as an asymptomatic pelvic mass or with pressure symptoms, not PMB. * **Hilus Cell Tumor:** A subtype of Leydig cell tumor that is androgenic. While they occur in post-menopausal women, they cause masculinization due to testosterone production. **NEET-PG High-Yield Pearls:** 1. **Tumor Marker:** **Inhibin (Inhibin B)** is the specific tumor marker used for the diagnosis and monitoring of Granulosa cell tumors. 2. **Endometrial Association:** Approximately 5–10% of patients with GCT may have a co-existing **Endometrial Carcinoma** due to prolonged estrogen stimulation. 3. **Most common cause of PMB:** Overall, the most common cause is **Atrophic Vaginitis/Endometritis**, but the most important cause to rule out is Endometrial Carcinoma.

Q: A 25-year-old married nullipara undergoes laparoscopic cystectomy for an ovarian cyst which, on histopathology, reveals ovarian serous cystadenocarcinoma. What should be the next management step?

Unilateral salpingo-oophorectomy. **Explanation:** The core concept here is **Fertility-Sparing Surgery (FSS)** in young patients with early-stage epithelial ovarian cancer. **Why Option C is Correct:** The patient is a 25-year-old nullipara (desires future fertility) with a diagnosis of ovarian serous cystadenocarcinoma. In young patients with **Stage IA (Grade 1 or 2)** epithelial ovarian cancer, the standard of care is fertility-sparing surgery. This involves a **Unilateral Salpingo-oophorectomy (USO)** with surgical staging (omental biopsy, peritoneal washings, and lymph node sampling) while preserving the uterus and the contralateral ovary. Since the initial procedure was only a cystectomy (which carries a risk of tumor spillage and incomplete resection), a completion USO is necessary to ensure oncological safety. **Why Other Options are Incorrect:** * **Option A:** Serial Ca-125 is used for monitoring recurrence but is never a primary treatment for a confirmed malignancy. * **Option B:** Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo-oophorectomy (BSO) is the standard treatment for postmenopausal women or those who have completed their family. In this 25-year-old nullipara, it would be unnecessarily radical. * **Option D:** Radiotherapy has a very limited role in the primary management of epithelial ovarian cancer; chemotherapy (Taxanes + Platinum) is the preferred adjuvant modality if indicated. **Clinical Pearls for NEET-PG:** * **Staging:** Ovarian cancer is staged surgically (FIGO staging). * **Fertility Sparing:** Only indicated for Stage IA/IC1 and Grade 1/2 tumors. * **Cystectomy vs. USO:** Simple cystectomy is discouraged in suspected malignancy due to the high risk of rupture and upstaging the disease from IA to IC1. * **Most common type:** Serous cystadenocarcinoma is the most common malignant epithelial ovarian tumor.

Q: A patient presents with stage IB carcinoma of the cervix. The tumor extends to the lower third of the vagina, the body of the uterus, and the upper part of the cervix. What is the next step in management?

Surgery. **Explanation:** The management of cervical cancer is primarily determined by the **FIGO staging**. In this case, the patient is diagnosed with **Stage IB**. According to FIGO guidelines, Stage IA to IIA (early-stage cervical cancer) is primarily managed with **Radical Hysterectomy (Type III/Wertheim’s Hysterectomy)** and bilateral pelvic lymphadenectomy. **Why Surgery is Correct:** For Stage IB, surgery is the treatment of choice as it allows for ovarian preservation (important in young patients) and provides better assessment of lymph node status. The extension to the **body of the uterus** does not change the stage or the surgical approach. While the question mentions the "lower third of the vagina," this is a common distractor; if the tumor *originated* in the cervix and is classified as Stage IB, the primary management remains surgical. **Why Other Options are Wrong:** * **A & B (Chemotherapy):** Chemotherapy alone is not a primary treatment for early-stage cervical cancer. It is usually used as a radiosensitizer (Concurrent Chemoradiotherapy) for locally advanced stages (IIB to IVA). * **D (Surgery followed by radiotherapy):** While adjuvant radiotherapy may be required if post-operative histopathology shows high-risk features (positive margins, lymph nodes, or parametrial involvement), the **immediate next step** in management for Stage IB is the surgery itself. **High-Yield Clinical Pearls for NEET-PG:** * **Stage IA1:** Simple hysterectomy (or conization if fertility is desired). * **Stage IB1 to IIA1:** Radical Hysterectomy is the gold standard. * **Stage IIB onwards:** Concurrent Chemoradiotherapy (CCRT) is the treatment of choice. * **Extension to the Uterine Body:** This does **not** alter the FIGO stage of cervical cancer. * **Most common cause of death:** Uremia due to ureteric obstruction.

Q: Which of the following tumors does NOT metastasize to the ovary?

Cervical carcinoma. **Explanation:** The ovary is a common site for metastatic spread from various primary malignancies. Metastatic tumors to the ovary are known as **secondary ovarian tumors**, accounting for approximately 10–25% of all ovarian malignancies. **Why Cervical Carcinoma is the Correct Answer:** Cervical carcinoma (Option C) rarely metastasizes to the ovary. Squamous cell carcinoma of the cervix, the most common histological type, has an extremely low incidence of ovarian metastasis (<1%). While adenocarcinoma of the cervix has a slightly higher risk, it is still clinically rare compared to the other options. Cervical cancer primarily spreads via direct extension to the parametrium and vagina or through the lymphatic system to the pelvic and para-aortic nodes. **Analysis of Incorrect Options:** * **Gastric Carcinoma (A):** This is the classic primary site for a **Krukenberg tumor**. It spreads to the ovaries via retrograde lymphatic spread or transcoelomic seeding. * **Colonic Carcinoma (B):** Large bowel malignancies are a frequent source of ovarian metastases. They often mimic primary mucinous ovarian cystadenocarcinomas. * **Breast Carcinoma (D):** Breast cancer is the most common non-gastrointestinal source of ovarian metastasis. It often presents as bilateral, small, solid ovarian masses. **High-Yield NEET-PG Pearls:** 1. **Krukenberg Tumor:** Characterized by bilateral ovarian involvement, "signet-ring" cells on histology, and a primary site usually in the **stomach** (most common) or colon. 2. **Common Primaries:** The most frequent sources of ovarian metastases are the **Stomach, Colon, and Breast**. 3. **Route of Spread:** Most secondary ovarian tumors spread via the **lymphatic route** rather than direct seeding. 4. **Clinical Clue:** If an ovarian mass is **bilateral and solid**, always suspect a metastatic origin and perform a thorough gastrointestinal and breast evaluation.

Q: Which condition is associated with the largest ovarian tumors?

Pseudomucinous cystadenoma. **Explanation:** **Pseudomucinous cystadenoma** (Mucinous cystadenoma) is the correct answer because these tumors are notorious for reaching massive proportions, often filling the entire abdominal cavity. They are the **largest tumors occurring in the human body**, sometimes weighing over 20–30 kg. **Why it is correct:** Mucinous cystadenomas are lined by tall columnar epithelium (resembling endocervical or intestinal mucosa) that secretes thick, viscous mucin. Unlike serous tumors, they are typically **multiloculated** with smooth surfaces and rarely present bilaterally (only 5–10%). Their ability to remain asymptomatic while slowly expanding allows them to reach a giant size before the patient seeks medical attention due to abdominal girth increase. **Why other options are incorrect:** * **Serous cystadenoma:** These are the most common benign ovarian tumors. While they can be large, they are generally smaller than mucinous types and are more frequently bilateral (25%). * **Papillary cystadenoma:** This is a morphological variant (often of serous tumors) characterized by internal projections. They are associated with a higher risk of malignancy but do not typically reach the "giant" dimensions of mucinous tumors. * **Dysgerminoma:** This is a germ cell tumor. While it can grow rapidly, it usually presents in younger women as a solid mass and does not reach the massive cystic proportions seen in mucinous cystadenomas. **High-Yield Clinical Pearls for NEET-PG:** * **Pseudomyxoma Peritonei:** A rare complication where a mucinous tumor (often from the appendix) ruptures, filling the peritoneal cavity with "jelly belly." * **Microscopic Hallmark:** Tall columnar cells with apical mucin and basal nuclei. * **Size Fact:** If a question mentions a "huge abdominal mass" or "giant cyst" in a middle-aged woman, think Mucinous Cystadenoma.

Q: A 52-year-old postmenopausal female presents with a 6 cm unilocular ovarian cyst and normal CA-125 levels. What is the most appropriate management?

Watchful waiting. **Explanation:** The management of postmenopausal ovarian cysts depends on the risk of malignancy. According to current guidelines (RCOG and ACOG), a **simple, unilocular, asymptomatic cyst** measuring **less than 5 cm to 10 cm** in a postmenopausal woman with a **normal CA-125** level carries a very low risk of malignancy (<1%). **1. Why Watchful Waiting is Correct:** In this patient, the cyst is unilocular (low-risk morphology), relatively small (6 cm), and the CA-125 is normal. The most appropriate initial step is "Watchful Waiting" with serial transvaginal ultrasound (TVUS) every 4–6 months. Many such cysts are functional or benign (e.g., serous cystadenomas) and may resolve or remain stable without intervention. **2. Why Other Options are Incorrect:** * **A. Ultrasound-guided aspiration:** This is contraindicated in postmenopausal cysts. If the cyst is malignant, aspiration can cause intraperitoneal seeding (upstaging the cancer). Furthermore, recurrence rates are high. * **C. Surgical intervention:** Surgery (Laparoscopic oophorectomy) is reserved for cysts that are symptomatic, >10 cm, have solid components/septations (complex), or are associated with rising CA-125 levels. * **D. Oral contraceptive pills:** These are used to suppress functional cysts in premenopausal women. They have no role in treating existing cysts in postmenopausal women. **Clinical Pearls for NEET-PG:** * **RMI (Risk of Malignancy Index):** Uses Menopausal status (M), Ultrasound features (U), and CA-125 levels. A score >200 usually warrants surgical referral. * **CA-125 Cut-off:** In postmenopausal women, a CA-125 value **>35 IU/ml** is considered significant. * **Most common benign ovarian tumor in postmenopausal women:** Serous cystadenoma. * **Most common malignant ovarian tumor:** Serous cystadenocarcinoma.

Question 1

What is the stage of an ovarian tumor if only one ovary is involved, without surface involvement or rupture?

Accepted Answer

Stage IA

Answer

Stage IB

Answer

Stage IC1

Answer

Stage IC2

Question 2

CA 125 is primarily used for which of the following purposes?

Accepted Answer

Follow-up monitoring of ovarian cancer

Answer

Diagnosis of pancreatic cancer

Answer

Diagnosis of stomach cancer

Answer

Diagnosis of ovarian cancer

Question 3

A 35-year-old female presents with postcoital bleeding. What is the next appropriate step in management?

Accepted Answer

Pap smear along with clinical examination

Answer

Visual examination with Lugol's iodine

Answer

Visual examination with acetic acid

Answer

Colposcopy-directed biopsy

Question 4

A 55-year-old lady presents with postmenopausal bleeding for 3 months and a 1 x 1 cm nodule on the anterior lip of the cervix. What is the most appropriate investigation to be done subsequently?

Accepted Answer

Punch biopsy

Answer

Pap smear

Answer

Endocervical curettage

Answer

Colposcopy

Question 5

Which of the following is a cause of post-menopausal bleeding?

Accepted Answer

Granulosa cell tumor

Answer

Arrhenoblastoma

Answer

Cystadenoma

Answer

Hilus cell tumor

Question 6

A 25-year-old married nullipara undergoes laparoscopic cystectomy for an ovarian cyst which, on histopathology, reveals ovarian serous cystadenocarcinoma. What should be the next management step?

Accepted Answer

Unilateral salpingo-oophorectomy

Answer

Serial Ca-125 measurement and follow-up

Answer

Hysterectomy and bilateral salpingo-oophorectomy

Answer

Radiotherapy

Question 7

A patient presents with stage IB carcinoma of the cervix. The tumor extends to the lower third of the vagina, the body of the uterus, and the upper part of the cervix. What is the next step in management?

Accepted Answer

Surgery

Answer

Chemotherapy

Answer

Surgery followed by chemotherapy

Answer

Surgery followed by radiotherapy

Question 8

Which of the following tumors does NOT metastasize to the ovary?

Accepted Answer

Cervical carcinoma

Answer

Gastric carcinoma

Answer

Colonic carcinoma

Answer

Breast carcinoma

Question 9

Which condition is associated with the largest ovarian tumors?

Accepted Answer

Pseudomucinous cystadenoma

Answer

Serous cystadenoma

Answer

Papillary cystadenoma

Answer

Dysgerminoma

Question 10

A 52-year-old postmenopausal female presents with a 6 cm unilocular ovarian cyst and normal CA-125 levels. What is the most appropriate management?

Accepted Answer

Watchful waiting

Answer

Ultrasound-guided ovarian cyst aspiration

Answer

Surgical intervention

Answer

Oral contraceptive pills

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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