Gynecologic Oncology Practice Questions

Q: A 50-year-old lady presents with a two-month history of postmenopausal bleeding. On vaginal examination, a 1 x 2 cm growth is found on the anterior lip of the cervix. The uterus is of normal size, and rectal examination reveals free rectal mucosa and parametrium. Punch biopsy of the lesion establishes a diagnosis of cervical cancer. What is the recommended management?

Radical hysterectomy and pelvic lymphadenectomy. ### Explanation **Clinical Staging and Diagnosis:** The patient presents with a visible cervical lesion (1 x 2 cm) and postmenopausal bleeding. Based on the clinical findings: * **Size:** 2 cm (limited to the cervix). * **Parametrium:** Free (no involvement). * **Vaginal/Rectal mucosa:** Free. This corresponds to **FIGO Stage IB1** (clinically visible lesion ≤ 2 cm in greatest dimension, limited to the cervix). **Why Option C is Correct:** For early-stage cervical cancer (Stage IA2 to IB2), the standard of care is **Radical Hysterectomy (Type III/Wertheim’s) with Pelvic Lymphadenectomy**. This procedure is preferred in fit, younger patients (like this 50-year-old) to preserve vaginal function and avoid the long-term sequelae of radiation. **Why Other Options are Incorrect:** * **Option A (Conization):** This is only indicated for Stage IA1 (microinvasive) disease when fertility preservation is desired. It is insufficient for a 2 cm visible lesion. * **Option B (Type 1 Hysterectomy):** Simple hysterectomy is inadequate for Stage IB1 as it does not address the parametrium or pelvic lymph nodes, leading to a high risk of recurrence. * **Option D (Concurrent Chemoradiation):** This is the treatment of choice for **locally advanced cervical cancer (Stage IIB to IVA)**. While it is as effective as surgery for Stage IB1, surgery is generally preferred to avoid radiation-induced vaginal atrophy and menopause. **NEET-PG High-Yield Pearls:** 1. **Staging:** Cervical cancer is staged **clinically** (FIGO). 2. **Cut-off for Surgery:** Stage IIB (parametrial involvement) is the "point of no return" for surgery; these patients must receive Chemoradiation. 3. **Most Common Node:** The **Obturator node** is the most common lymph node involved in cervical cancer. 4. **Triad of Stage IIIB:** Hydronephrosis, non-functioning kidney, or involvement of the pelvic wall.

Q: An 18-year-old female presents with an ovarian mass, and her serum LDH and placental alkaline phosphatase are found to be elevated. What is the treatment of choice in this condition?

Oophorectomy on the involved side. ### Explanation **Diagnosis: Dysgerminoma** The clinical presentation of an 18-year-old female with an ovarian mass and elevated **Serum LDH** and **Placental Alkaline Phosphatase (PLAP)** is pathognomonic for a **Dysgerminoma**. This is the most common malignant germ cell tumor (GCT) in young women. **Why Option B is Correct:** Malignant germ cell tumors, unlike epithelial ovarian cancers, are usually unilateral (except dysgerminoma, which is bilateral in 10-15% of cases) and occur in women of reproductive age. The standard of care is **Unilateral Salpingo-oophorectomy (USO)** to preserve fertility, even if the tumor is large, as these tumors are highly chemosensitive. **Why Other Options are Incorrect:** * **Option A:** Bilateral oophorectomy is avoided to preserve hormonal and reproductive function. While dysgerminomas are highly radiosensitive, radiotherapy is no longer the primary treatment because it causes permanent infertility. * **Option C:** Surgery is the primary step for diagnosis, staging, and debulking. Chemotherapy (usually the BEP regimen) is used as adjuvant therapy for higher stages, not as a standalone primary treatment. * **Option D:** Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH+BSO) is the treatment for epithelial ovarian cancer in postmenopausal women but is considered overtreatment for a young patient with a germ cell tumor. **Clinical Pearls for NEET-PG:** * **Tumor Markers:** LDH and PLAP (Dysgerminoma), AFP (Yolk Sac Tumor), hCG (Choriocarcinoma). * **Most common GCT in pregnancy:** Dysgerminoma. * **Associated Condition:** Dysgerminomas are frequently associated with **gonadal dysgenesis** (Swyer Syndrome); if a Y-chromosome is present, a bilateral gonadectomy is indicated. * **Chemotherapy:** The **BEP regimen** (Bleomycin, Etoposide, Cisplatin) is the gold standard for malignant GCTs.

Q: Which of the following is true regarding the cervical cancer vaccine?

The most common causative subtypes are HPV 16 and 18.. **Explanation:** **Correct Option (C):** Human Papillomavirus (HPV) is the primary etiological agent for cervical cancer. Among the high-risk oncogenic types, **HPV 16 and 18** are the most common, accounting for approximately **70% of all cervical cancer cases** worldwide. HPV 16 is specifically associated with squamous cell carcinoma, while HPV 18 is more frequently linked to adenocarcinoma. **Analysis of Incorrect Options:** * **Option A:** While bivalent (Cervarix) and quadrivalent (Gardasil) vaccines were the initial options, the **Nonavalent vaccine (Gardasil 9)** is now the standard of care in many regions, covering five additional oncogenic types (31, 33, 45, 52, 58). * **Option B:** The primary target group for the HPV vaccine is **adolescent girls (9–14 years)** before sexual debut. While catch-up vaccination is recommended up to age 26 (and can be given up to 45 years based on shared clinical decision-making), it is not specifically targeted at "married women." * **Option D:** The dosage schedule depends on age. For girls aged **9–14 years, a 2-dose schedule** (0, 6 months) is recommended. However, for those **15 years and older** or immunocompromised individuals, a **3-dose schedule** (0, 1-2, 6 months) is mandatory. **High-Yield Clinical Pearls for NEET-PG:** * **L1 Protein:** The vaccine consists of virus-like particles (VLPs) derived from the L1 capsid protein. * **HPV 6 & 11:** These are low-risk types responsible for 90% of genital warts (Condyloma acuminata), covered by quadrivalent and nonavalent vaccines. * **Screening:** Vaccination does not replace cervical cancer screening; Pap smears/HPV DNA testing should continue as per protocols. * **WHO 2022 Update:** A single-dose schedule is now considered off-label but effective for the primary target group (9-14 years) in resource-limited settings.

Q: A patient with carcinoma of the cervix presents with altered sensorium and hiccups. What is the likely cause?

Uremia. **Explanation:** In advanced stages of **Carcinoma Cervix**, the most common cause of death is **renal failure** resulting from obstructive uropathy. **1. Why Uremia is the correct answer:** As the cervical tumor spreads laterally into the parametrium, it can cause extrinsic compression of the ureters. This leads to bilateral hydroureter and hydronephrosis, eventually resulting in post-renal acute kidney injury or chronic kidney disease. The accumulation of nitrogenous waste products (Uremia) affects the central nervous system, leading to **altered sensorium** (uremic encephalopathy). Furthermore, uremia irritates the phrenic nerve or the diaphragm, which is a classic cause of persistent **hiccups**. **2. Why other options are incorrect:** * **Septicemia:** While advanced cancer patients are prone to infections, septicemia typically presents with fever, tachycardia, and hypotension. While it can cause altered sensorium (septic encephalopathy), it is not the classic association for hiccups in this clinical context. * **Raised Intracranial Pressure (ICP):** This would suggest brain metastasis. However, Carcinoma Cervix primarily spreads locally or to regional lymph nodes; distant metastasis to the brain is extremely rare. **Clinical Pearls for NEET-PG:** * **Most common cause of death in Ca Cervix:** Uremia (Renal Failure). * **Triad of advanced Ca Cervix:** Leg edema, sciatic pain, and hydronephrosis (indicates pelvic wall involvement). * **Staging:** According to FIGO staging, hydronephrosis or a non-functioning kidney automatically classifies the disease as **Stage IIIB**, regardless of other findings. * **Management of Ureteral Obstruction:** Percutaneous Nephrostomy (PCN) or double-J (DJ) stenting is often required as palliative measures.

Q: Sentinel lymph node biopsy is indicated in which of the following gynecological malignancies, except?

Choriocarcinoma. ### Explanation The correct answer is **D. Choriocarcinoma**. **Why Choriocarcinoma is the correct answer:** Sentinel Lymph Node (SLN) biopsy is a technique used to identify the first node(s) receiving lymphatic drainage from a primary tumor to assess for regional spread. **Choriocarcinoma** is a highly malignant germ cell or gestational trophoblastic neoplasm characterized by early and aggressive **hematogenous spread** (primarily to the lungs and brain) rather than lymphatic spread. Therefore, surgical staging or lymph node assessment via SLN biopsy has no clinical role in its management. **Analysis of other options:** * **Carcinoma of the Vulva:** SLN biopsy is the standard of care for early-stage vulvar cancer (Stage T1/T2, <4 cm) with clinically negative nodes. It significantly reduces the morbidity associated with radical inguinofemoral lymphadenectomy. * **Carcinoma of the Cervix:** SLN mapping is increasingly used in early-stage cervical cancer (Stage IA2, IB1, and IB2) to avoid the complications of full pelvic lymphadenectomy while maintaining oncological safety. * **Carcinoma of the Breast:** This is the "gold standard" indication for SLN biopsy. It is used for clinically node-negative (cN0) patients to determine the need for axillary lymph node dissection. **High-Yield Clinical Pearls for NEET-PG:** * **Tracers used for SLN:** Technetium-99m (99mTc) sulfur colloid, Isosulfan blue/Methylene blue, or Indocyanine Green (ICG). * **Vulvar Cancer Criteria:** SLN is indicated if the tumor is unifocal, <4 cm, and has no clinical evidence of nodal involvement. * **Choriocarcinoma Marker:** The most important diagnostic and follow-up marker is **beta-hCG**. It is highly sensitive to chemotherapy (EMA-CO regimen). * **Most common site of metastasis in Choriocarcinoma:** Lungs (presents as "cannonball" appearance on X-ray).

Q: What is used for post-evacuation surveillance of molar pregnancy?

b-hCG. **Explanation:** **Molar pregnancy (Hydatidiform mole)** is a part of Gestational Trophoblastic Disease (GTD). The definitive management is suction and evacuation; however, there is a risk of progression to Gestational Trophoblastic Neoplasia (GTN). **Why b-hCG is the correct answer:** Human chorionic gonadotropin (hCG) is secreted by the proliferating syncytiotrophoblasts. Since molar tissue is entirely composed of trophoblastic proliferation, **serum b-hCG** serves as a highly sensitive and specific tumor marker. Post-evacuation, b-hCG levels should ideally fall to undetectable levels. Serial monitoring is mandatory to detect persistent disease or malignant transformation (Choriocarcinoma). **Why other options are incorrect:** * **AFP (Alpha-fetoprotein):** Used for monitoring germ cell tumors (Yolk sac tumor) and Hepatocellular carcinoma. * **LDH (Lactate Dehydrogenase):** A non-specific marker, though specifically elevated in Dysgerminomas. * **CA 125:** The primary marker for epithelial ovarian tumors; it has no role in trophoblastic disease. **High-Yield Clinical Pearls for NEET-PG:** * **Follow-up Protocol:** Weekly b-hCG levels until three consecutive negative results (<5 mIU/ml), followed by monthly levels for 6 months. * **Contraception:** Patients must use reliable contraception (preferably Barrier or OCPs) during the surveillance period to avoid a new pregnancy, which would confuse b-hCG interpretation. * **GTN Diagnosis:** According to FIGO criteria, GTN is diagnosed if b-hCG levels plateau (4 values over 3 weeks) or rise (3 values over 2 weeks). * **Snowstorm appearance** on ultrasound is the classic diagnostic feature of a complete mole.

Q: What is the staging of carcinoma of the cervix with parametrial involvement?

Stage II B. **Explanation:** The staging of cervical cancer is primarily clinical and follows the **FIGO (2018) classification**. Understanding the anatomical spread is key to identifying the correct stage. **1. Why Stage II B is Correct:** Stage II is defined as carcinoma that extends beyond the uterus but has not reached the pelvic wall or the lower third of the vagina. Specifically, **Stage II B** indicates **parametrial involvement** that does not extend to the pelvic sidewall. This is a critical clinical distinction because Stage II B is generally treated with primary chemoradiation rather than surgery. **2. Why the Other Options are Incorrect:** * **Stage III A:** Involves the lower third of the vagina but does **not** extend to the pelvic sidewall. * **Stage III B:** Extension to the **pelvic sidewall** and/or causes hydronephrosis or a non-functioning kidney. While it involves the parametrium, it is more advanced than simple parametrial involvement. * **Stage III C:** This stage is reserved for metastasis to the **pelvic (III C1) or para-aortic (III C2) lymph nodes**, regardless of the size of the primary tumor. **Clinical Pearls for NEET-PG:** * **The "Cut-off" for Surgery:** Generally, Stage I A to II A can be treated surgically (e.g., Radical Hysterectomy). From **Stage II B onwards**, the standard of care shifts to **Concurrent Chemoradiation**. * **Hydronephrosis:** If a patient has parametrial involvement and hydronephrosis, the stage automatically upgrades to **III B**. * **FIGO 2018 Update:** Remember that lymph node status (Stage III C) and imaging/pathology are now included in staging, unlike the older clinical-only versions.

Q: What is the most common tumor of the cervix?

Squamous cell carcinoma. **Explanation:** **1. Why Squamous Cell Carcinoma (SCC) is correct:** Squamous cell carcinoma is the most common histological type of cervical cancer, accounting for approximately **75–80%** of all cases. It originates from the squamous epithelium of the ectocervix, typically at the **transformation zone** (the junction where columnar epithelium is replaced by squamous epithelium). The primary etiological factor is persistent infection with high-risk Human Papillomavirus (HPV) types 16 and 18. **2. Why the other options are incorrect:** * **B. Adenocarcinoma:** This is the second most common type, accounting for about **15–20%** of cases. It arises from the mucus-secreting glandular epithelium of the endocervix. Its incidence has been rising relatively due to better screening for SCC (Pap smears are more effective at detecting squamous lesions than glandular ones). * **C. Sarcoma:** Primary cervical sarcomas (e.g., leiomyosarcoma, endocervical stromal sarcoma) are extremely rare, representing less than 1% of all cervical malignancies. * **D. Adenoacanthoma:** This is a historical term for an adenocarcinoma with squamous metaplasia. It is rare in the cervix and more commonly associated with the endometrium. **3. Clinical Pearls for NEET-PG:** * **Most common site:** Transformation zone. * **Most common HPV types:** HPV 16 (most common for SCC) and HPV 18 (highly associated with Adenocarcinoma). * **Screening:** The Pap smear is the gold standard for secondary prevention; the most common finding is LSIL or HSIL. * **Staging:** Cervical cancer is staged **clinically** (FIGO staging), though the 2018 update now allows for imaging and pathological findings where available. * **Route of spread:** The most common route is **direct extension** (into the paracervical tissues/parametrium).

Q: A patient presents with carcinoma endometrium involving more than 50% of the myometrium, extending to the vagina, and positive peritoneal cytology, but no involvement of para-aortic and pre-aortic nodes. What is the stage of the disease?

Stage III B. ### Explanation The staging of endometrial carcinoma is based on the **FIGO 2023 (and 2009)** surgical staging system. To determine the correct stage, we must analyze the extent of local and regional spread. **1. Why Stage III B is correct:** Stage III indicates local and/or regional spread of the tumor. Specifically: * **Stage III A:** Involvement of the uterine serosa and/or adnexa (fallopian tubes/ovaries). * **Stage III B:** Involvement of the **vagina** and/or parametrium. In this case, the extension to the **vagina** automatically classifies the disease as **Stage III B**. **2. Why the other options are incorrect:** * **Stage III A:** This would be the answer if the tumor involved the serosa or adnexa. While the patient has positive peritoneal cytology, it is important to note that in the **FIGO 2009/2023 updates**, positive peritoneal cytology alone no longer changes the stage (though it should be recorded). * **Stage III C1:** This stage involves metastasis to the **pelvic lymph nodes**. The question states there is no nodal involvement. * **Stage III C2:** This involves metastasis to the **para-aortic lymph nodes**, with or without pelvic nodes. The question explicitly rules out para-aortic/pre-aortic involvement. **Clinical Pearls for NEET-PG:** * **FIGO Staging is Surgical:** Endometrial cancer is staged surgically (unlike Cervical Cancer, which was traditionally clinical but is now a hybrid). * **Myometrial Invasion:** Involvement of >50% myometrium (without extrauterine spread) would be **Stage I B**. * **Peritoneal Cytology:** Since 2009, positive cytology is reported but does not upstage the disease. * **Most Common Site of Spread:** Direct extension is common, but the most common site of distant metastasis is the lungs.

Question 1

A 50-year-old lady presents with a two-month history of postmenopausal bleeding. On vaginal examination, a 1 x 2 cm growth is found on the anterior lip of the cervix. The uterus is of normal size, and rectal examination reveals free rectal mucosa and parametrium. Punch biopsy of the lesion establishes a diagnosis of cervical cancer. What is the recommended management?

Accepted Answer

Radical hysterectomy and pelvic lymphadenectomy

Answer

Conization

Answer

Type 1 Hysterectomy

Answer

Concurrent chemoradiation

Question 2

An 18-year-old female presents with an ovarian mass, and her serum LDH and placental alkaline phosphatase are found to be elevated. What is the treatment of choice in this condition?

Accepted Answer

Oophorectomy on the involved side

Answer

Bilateral oophorectomy and postoperative radiotherapy

Answer

Chemotherapy only

Answer

Hysterectomy with bilateral salpingo-oophorectomy

Question 3

Which of the following is true regarding the cervical cancer vaccine?

Accepted Answer

The most common causative subtypes are HPV 16 and 18.

Answer

Bivalent and quadrivalent vaccines are available.

Answer

It is given to married women in the 20-45 years age group.

Answer

Two doses are given.

Question 4

A patient with carcinoma of the cervix presents with altered sensorium and hiccups. What is the likely cause?

Accepted Answer

Uremia

Answer

Septicemia

Answer

Raised intracranial pressure

Answer

None of the above

Question 5

Sentinel lymph node biopsy is indicated in which of the following gynecological malignancies, except?

Accepted Answer

Choriocarcinoma

Answer

Carcinoma of the vulva

Answer

Carcinoma of the cervix

Answer

Carcinoma of the breast

Question 6

What is used for post-evacuation surveillance of molar pregnancy?

Accepted Answer

b-hCG

Answer

AFP

Answer

LDH

Answer

CA 125

Question 7

What is the staging of carcinoma of the cervix with parametrial involvement?

Accepted Answer

Stage II B

Answer

Stage III C

Answer

Stage III A

Answer

Stage III B

Question 8

What is the most common tumor of the cervix?

Accepted Answer

Squamous cell carcinoma

Answer

Adenocarcinoma

Answer

Sarcoma

Answer

Adenoacanthoma

Question 9

Which of the following is NOT an advantage of surgery over radiotherapy in the management of carcinoma of the cervix?

Accepted Answer

Low operative mortality

Answer

Conservation of ovaries

Answer

Preservation of sexual function

Answer

None of the above

Question 10

A patient presents with carcinoma endometrium involving more than 50% of the myometrium, extending to the vagina, and positive peritoneal cytology, but no involvement of para-aortic and pre-aortic nodes. What is the stage of the disease?

Accepted Answer

Stage III B

Answer

Stage III A

Answer

Stage III C1

Answer

Stage III C2

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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