Gynecologic Oncology Practice Questions

Q: A left-sided ovarian tumor is noted with HCG 4 IU/L, normal AFP, and elevated LDH. What is the most likely diagnosis?

Dysgerminoma. **Explanation:** The correct diagnosis is **Dysgerminoma**. This is the most common malignant germ cell tumor (GCT) of the ovary, typically occurring in young women. **Why Dysgerminoma is correct:** Dysgerminomas are characterized by a specific biochemical profile: * **LDH (Lactate Dehydrogenase):** This is the most sensitive and characteristic marker for Dysgerminoma. * **HCG:** While primarily associated with choriocarcinoma, about 5% of Dysgerminomas contain syncytiotrophoblastic giant cells which produce low levels of HCG (usually 100,000 IU/L). A level of 4 IU/L is too low for a primary choriocarcinoma. * **Embryonal cell tumor:** These are rare and typically secrete **both** AFP and HCG. * **Malignant Teratoma (Immature Teratoma):** These usually present with elevated **AFP** (in 50% of cases) or are non-secretory. They are not typically associated with isolated high LDH. **NEET-PG High-Yield Pearls:** 1. **Dysgerminoma** is the ovarian counterpart of testicular **Seminoma**. 2. It is the most common germ cell tumor associated with **pregnancy** and **gonadal dysgenesis** (Swyer Syndrome). 3. **Microscopy:** Look for "Fried egg appearance" (clear cytoplasm, central nuclei) and fibrous septa infiltrated with **lymphocytes**. 4. It is highly **radiosensitive**, though fertility-sparing surgery followed by chemotherapy (BEP regimen) is the standard of care.

Q: Colposcopic features suggestive of malignancy are all except:

Condyloma. In colposcopy, the primary goal is to identify **Atypical Transformation Zones (ATZ)** that suggest Cervical Intraepithelial Neoplasia (CIN) or invasive cancer. ### **Explanation of the Correct Answer** **A. Condyloma:** These are genital warts caused by low-risk HPV types (6 and 11). On colposcopy, they appear as exophytic, cauliflower-like, or micropapillary lesions. While they are an abnormal finding, they are considered **benign** and are not markers of malignancy or high-grade dysplasia. ### **Analysis of Incorrect Options (Features of Malignancy)** The following are hallmarks of high-grade lesions (CIN II/III) or malignancy: * **D. White Epithelium (Acetowhite):** When acetic acid (3-5%) is applied, areas with high nuclear density and protein content coagulate, appearing white. Thick, opaque, "leathery" acetowhite areas with rapid uptake are highly suggestive of high-grade lesions. * **C. Punctation:** This represents dilated capillaries reaching the surface in a "dotted" pattern. Coarse punctation (large, widely spaced dots) is a sign of high-grade dysplasia. * **B. Vascular Atypia:** This is the most concerning feature. It refers to "atypical vessels" that are irregular in size, shape, and course (e.g., comma-shaped, corkscrew, or spaghetti-like vessels). These indicate neoangiogenesis associated with invasive cancer. ### **High-Yield Clinical Pearls for NEET-PG** * **Reid’s Colposcopic Index (RCI):** A scoring system (0-8) used to grade the severity of lesions based on color, margin, vessels, and iodine staining. * **Schiller’s Test:** Uses Lugol’s iodine. Normal cells (rich in glycogen) stain mahogany brown (**Iodine positive**). Malignant/dysplastic cells (glycogen depleted) do not take up the stain and appear yellow/pale (**Iodine negative**). * **Mosaicism:** Another feature of ATZ where capillaries form a "tile-like" or "honeycomb" pattern. Coarse mosaicism suggests high-grade disease.

Q: A patient presents with abdominal discomfort, bloating, and pain. An MRI shows bilateral ovarian tumors with involvement of pelvic lymph nodes and the liver capsule. What is the appropriate staging of this ovarian tumor?

Stage 3. ### Explanation The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) system**, which is primarily surgical but can be assessed via imaging for clinical management. **Why Stage 3 is Correct:** Stage 3 is defined by the spread of the tumor to the **peritoneum outside the pelvis** and/or involvement of the **retroperitoneal lymph nodes**. * **Liver Capsule Involvement:** According to FIGO staging, involvement of the liver capsule (surface) is classified as **Stage 3C**. This is distinct from liver parenchyma involvement, which would be Stage 4. * **Lymph Nodes:** Involvement of pelvic or para-aortic lymph nodes also places the disease in Stage 3 (specifically Stage 3A1). Since this patient has both pelvic lymph node involvement and liver capsule spread, Stage 3 is the most accurate classification. **Why Other Options are Incorrect:** * **Stage 1:** The tumor is strictly limited to one or both ovaries or fallopian tubes. This patient has spread beyond the adnexa. * **Stage 2A:** Involvement is limited to the uterus and/or fallopian tubes. * **Stage 2B:** Involvement extends to other pelvic intraperitoneal tissues (e.g., bladder, rectum) but remains **within the true pelvis**. The liver capsule is an extrapelvic site, ruling out Stage 2. **High-Yield Clinical Pearls for NEET-PG:** * **Stage 3C vs. Stage 4:** Remember the "Capsule vs. Parenchyma" rule. Spread to the **liver capsule** is Stage 3C; spread to the **liver parenchyma** (internal tissue) or pleural effusion with positive cytology is Stage 4. * **Most Common Presentation:** Most ovarian cancers (approx. 75%) are diagnosed at Stage 3 or 4 because early stages are often asymptomatic. * **CA-125:** While not used for staging, it is the most important marker for monitoring treatment response in epithelial ovarian tumors.

Q: Which stage of ovarian tumor involves the bladder?

Stage IIB. ### Explanation The staging of ovarian cancer follows the **FIGO (International Federation of Gynecology and Obstetrics) system**, which is primarily surgical. **1. Why Stage IIB is correct:** Stage II ovarian cancer is defined by growth involving one or both ovaries with **pelvic extension** (below the pelvic brim). * **Stage IIA:** Extension/metastases to the uterus or fallopian tubes. * **Stage IIB:** Extension to **other pelvic intraperitoneal tissues**, which specifically includes the **bladder** (serosa/surface) and the rectum. **2. Why the other options are incorrect:** * **Stage IIIA & IIIB:** These represent Stage III, which involves spread to the **peritoneum outside the pelvis** (extrapelvic) and/or metastasis to the retroperitoneal lymph nodes. Stage IIIA involves microscopic extrapelvic peritoneal involvement, while IIIB involves macroscopic involvement ≤ 2 cm. * **Stage IVA:** This represents distant metastasis. Specifically, Stage IVA is defined by **pleural effusion** with positive cytology. Stage IVB involves parenchymal metastases (liver/spleen) or extra-abdominal organ involvement. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Presentation:** Most ovarian cancers (approx. 75%) are diagnosed at **Stage III** because they remain asymptomatic until peritoneal seeding occurs. * **CA-125:** While used for monitoring, it is not specific for diagnosis as it can be elevated in endometriosis, PID, and pregnancy. * **Lymphatic Spread:** The primary lymphatic drainage of the ovaries is via the infundibulopelvic ligament to the **para-aortic lymph nodes**. * **Important Distinction:** If the tumor involves the bladder **mucosa** (transmural), it is still generally staged based on the extent of peritoneal spread, but Stage II specifically covers the pelvic organ surfaces.

Q: In carcinoma of the cervix, what is the primary causative etiological factor?

Human Papillomavirus (HPV) types 16 and 18. **Explanation:** The primary etiological factor in the development of cervical carcinoma is persistent infection with **High-Risk Human Papillomavirus (HR-HPV)**. Among the various high-risk strains, **HPV types 16 and 18** are the most oncogenic, responsible for approximately 70% of all cervical cancer cases worldwide. HPV 16 is most commonly associated with squamous cell carcinoma, while HPV 18 has a higher predilection for adenocarcinoma. The oncogenesis is driven by the viral oncoproteins **E6 and E7**, which inhibit the host tumor suppressor proteins **p53 and pRb**, respectively, leading to uncontrolled cell proliferation. **Analysis of Incorrect Options:** * **Option A & C:** **HPV types 6 and 11** are considered "low-risk" types. They are the primary cause of **Condyloma acuminata** (anogenital warts) and Recurrent Respiratory Papillomatosis. They rarely integrate into the host genome and do not typically lead to malignancy. * **Option D:** **Herpes Simplex Virus (HSV-2)** was historically suspected as a co-factor, but it is not a primary causative agent. It may act as a promoter by causing chronic inflammation, but it cannot induce cervical cancer independently. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** HPV 16 is the single most common type found in cervical cancer. * **Screening:** The transformation zone is the most common site for cervical neoplasia. * **Vaccination:** The Quadrivalent vaccine (Gardasil) covers types 6, 11, 16, and 18; the Nonavalent vaccine covers five additional high-risk types (31, 33, 45, 52, 58). * **Pathogenesis:** Integration of the viral genome into the host DNA is a hallmark of progression from CIN (Cervical Intraepithelial Neoplasia) to invasive cancer.

Q: Which of the following is NOT a cause of postmenopausal bleeding?

Carcinoma in situ of the cervix. **Explanation:** Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring at least 12 months after the cessation of menstruation. It is a "red flag" symptom that must always be investigated to rule out malignancy. **Why Option A is the Correct Answer:** **Carcinoma in situ (CIS)** of the cervix refers to pre-invasive neoplastic changes where the abnormal cells are confined to the epithelium and have not breached the basement membrane. Because there is no invasion into the underlying stroma or blood vessels, CIS is typically **asymptomatic** and does not cause clinical bleeding. Bleeding in cervical cancer only occurs once the lesion becomes **invasive** (Stage I and beyond). **Why the other options are incorrect:** * **Endometrial Carcinoma (B):** This is the most common cause of PMB among gynecological malignancies. Approximately 90% of patients with endometrial cancer present with PMB. * **Ovarian Carcinoma (C):** While less common, certain ovarian tumors (especially estrogen-secreting Germ cell or Sex cord-stromal tumors like Granulosa cell tumors) can cause endometrial hyperplasia, leading to PMB. * **Fallopian Tube Carcinoma (D):** Classically presents with the **Latzko’s Triad**: intermittent profuse serosanguinous vaginal discharge (*hydrops tubae profluens*), colicky pelvic pain, and a pelvic mass. **High-Yield NEET-PG Pearls:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (followed by endometrial polyps). * **Most common malignancy causing PMB:** Endometrial carcinoma. * **Investigation of choice for PMB:** Transvaginal Ultrasound (TVS). An **endometrial thickness (ET) > 4 mm** in a postmenopausal woman necessitates an endometrial biopsy to rule out malignancy. * **Gold Standard for diagnosis:** Fractional Curettage or Hysteroscopic-guided biopsy.

Q: Sentinel lymph node biopsy is useful for which of the following?

Carcinoma of the vulva. **Explanation:** The **Sentinel Lymph Node (SLN) biopsy** is a diagnostic procedure used to identify the first node(s) receiving lymphatic drainage from a primary tumor. If the SLN is negative for metastasis, the remaining nodes in that basin are likely negative, allowing the patient to avoid the morbidity of a full lymphadenectomy. **Why Carcinoma of the Vulva is correct:** In **early-stage vulvar cancer** (Stage IB or II, lesions <4 cm, and clinically N0 nodes), SLN biopsy using technetium-99m and/or isosulfan blue dye is the **standard of care**. It significantly reduces the risk of chronic lymphedema and wound complications associated with traditional inguinofemoral lymphadenectomy while maintaining oncologic safety. **Why other options are incorrect:** * **Carcinoma of the Fallopian Tube:** Management follows ovarian cancer protocols, which typically involve comprehensive surgical staging or debulking. SLN is not a standard approach here. * **Carcinoma of the Endometrium:** While SLN mapping is increasingly used in low-risk endometrial cancer (using indocyanine green), it is not yet the "classic" or most established indication in the same way it is for vulvar cancer in standard PG textbooks. * **Carcinoma of the Vagina:** Due to the complex and unpredictable lymphatic drainage of the vagina (upper vs. lower portions), SLN biopsy is not routinely recommended or standardized. **NEET-PG High-Yield Pearls:** * **Most common site for SLN in Vulvar Cancer:** Medial to the superficial epigastric vein in the groin. * **Ideal Candidate:** Unifocal tumor, <4 cm diameter, no clinically palpable nodes (cN0). * **Tracer used:** Technetium-99 (radioactive) and Methylene blue/Isosulfan blue. * **Other Cancers where SLN is standard:** Breast cancer and Malignant Melanoma.

Q: In which of the following genital tract malignancies is the risk of metastasis to the ovary the least?

Carcinoma cervix. **Explanation:** The risk of ovarian metastasis from genital tract malignancies depends on the anatomical proximity, shared lymphatic drainage, and the biological behavior of the primary tumor. **1. Why Carcinoma Cervix is the Correct Answer:** Squamous cell carcinoma (SCC) of the cervix has an exceptionally low rate of ovarian metastasis, estimated at **<1%**. Because of this low risk, **ovarian transposition** (moving the ovaries out of the pelvis) is a standard fertility-sparing procedure performed before pelvic radiation in young patients with cervical cancer. While adenocarcinoma of the cervix has a slightly higher risk (approx. 5–10%), it remains significantly lower than other uterine or tubal malignancies. **2. Why the Other Options are Incorrect:** * **Carcinoma Endometrium:** This is the most common malignancy to involve the ovaries, either via direct extension, lymphatic spread, or as a "synchronous" primary tumor. The risk is approximately **5–15%**. * **Carcinoma Fallopian Tube:** Due to direct anatomical continuity and the "fimbria-ovarian" relationship, the ovary is involved in the majority of cases. In fact, many high-grade serous "ovarian" cancers are now believed to originate in the fallopian tube (STIC lesions). * **Uterine Sarcoma:** These are aggressive tumors with a high propensity for hematogenous and local spread. The risk of ovarian involvement is roughly **5–10%**, which is significantly higher than in SCC of the cervix. **Clinical Pearls for NEET-PG:** * **Ovarian Transposition (Oopexy):** Performed in cervical cancer to preserve endocrine function before radiotherapy. * **Krukenberg Tumor:** Most commonly arises from the **Stomach** (Signet ring cells), not the genital tract. * **Most common site of metastasis to the ovary:** The **Colon** is the most common site of origin for metastatic ovarian tumors of intestinal type.

Q: Which of the following statements are true about Brenner tumor?

Resembles fibroma. **Explanation:** The **Brenner tumor** is a rare surface epithelial-stromal tumor of the ovary, characterized by nests of transitional epithelium (urothelium) embedded within a dense fibrous stroma. **Why Option B is correct:** Grossly and histologically, Brenner tumors contain an abundant amount of dense, spindle-celled stroma. This makes them firm, gritty, and solid, closely **resembling an ovarian fibroma** or theca cell tumor on visual inspection. **Analysis of Incorrect Options:** * **Option A:** Brenner tumors are **usually unilateral** (90-95% of cases). Bilaterality is rare, occurring in only about 5-10% of patients. * **Option C:** They are uncommon, accounting for only **1–2% of all ovarian tumors**, not 20%. * **Option D:** While they can occur at any age, the majority are found incidentally in women between **40 and 60 years of age** (perimenopausal). While some occur postmenopause, "resembling a fibroma" is a more definitive diagnostic characteristic frequently tested in exams. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** Look for the pathognomonic **"Coffee-bean nuclei"** (longitudinal nuclear grooves) in the transitional epithelial cells. * **Walthard Cell Rests:** These are benign clusters of transitional cells found in the Fallopian tubes/ovary, believed to be the precursors to Brenner tumors. * **Nature:** Most are benign; however, borderline and malignant variants exist. * **Association:** They are frequently associated with other epithelial tumors, most commonly **mucinous cystadenomas** in the same or contralateral ovary.

Question 1

A left-sided ovarian tumor is noted with HCG 4 IU/L, normal AFP, and elevated LDH. What is the most likely diagnosis?

Accepted Answer

Dysgerminoma

Answer

Choriocarcinoma

Answer

Embryonal cell tumor

Answer

Malignant Teratoma

Question 2

Colposcopic features suggestive of malignancy are all except:

Accepted Answer

Condyloma

Answer

Vascular atypia

Answer

Punctation

Answer

White epithelium

Question 3

Which ovarian tumor is most likely to be associated with virilization?

Accepted Answer

Sertoli-Leydig cell tumor

Answer

Granulosa cell tumor

Answer

Immature teratoma

Answer

Gonadoblastoma

Question 4

A patient presents with abdominal discomfort, bloating, and pain. An MRI shows bilateral ovarian tumors with involvement of pelvic lymph nodes and the liver capsule. What is the appropriate staging of this ovarian tumor?

Accepted Answer

Stage 3

Answer

Stage 1

Answer

Stage 2A

Answer

Stage 2B

Question 5

Which stage of ovarian tumor involves the bladder?

Accepted Answer

Stage IIB

Answer

Stage IIIA

Answer

Stage IIIB

Answer

Stage IVA

Question 6

In carcinoma of the cervix, what is the primary causative etiological factor?

Accepted Answer

Human Papillomavirus (HPV) types 16 and 18

Answer

Condyloma acuminata

Answer

Human Papillomavirus (HPV) types 6 and 11

Answer

Herpes Simplex Virus (HSV) 1 and 2

Question 7

Which of the following is NOT a cause of postmenopausal bleeding?

Accepted Answer

Carcinoma in situ of the cervix

Answer

Endometrial carcinoma

Answer

Ovarian carcinoma

Answer

Fallopian tube carcinoma

Question 8

Sentinel lymph node biopsy is useful for which of the following?

Accepted Answer

Carcinoma of the vulva

Answer

Carcinoma of the fallopian tube

Answer

Carcinoma of the endometrium

Answer

Carcinoma of the vagina

Question 9

In which of the following genital tract malignancies is the risk of metastasis to the ovary the least?

Accepted Answer

Carcinoma cervix

Answer

Carcinoma endometrium

Answer

Carcinoma fallopian tube

Answer

Uterine sarcoma

Question 10

Which of the following statements are true about Brenner tumor?

Accepted Answer

Resembles fibroma

Answer

Usually bilateral

Answer

Accounts for 20% of all ovarian tumors

Answer

Common in postmenopausal age group

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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