Gynecologic Oncology Practice Questions

Q: A 45-year-old lady complains of contact bleeding and has a positive Pap smear. What is the next line of management?

Colposcopy-directed biopsy. **Explanation:** The clinical presentation of **contact bleeding** (a hallmark symptom of cervical cancer) combined with an abnormal Pap smear is highly suspicious for cervical intraepithelial neoplasia (CIN) or invasive malignancy. **1. Why Colposcopy-directed Biopsy is the correct answer:** The Pap smear is a **screening tool**, not a diagnostic one. When a screening test is positive or clinical symptoms are suggestive, the standard "Next Step" in management is to visualize the cervix under magnification (Colposcopy) and take a **directed biopsy** from the most suspicious areas (e.g., acetowhite epithelium, punctations, or mosaicism). This provides a histological diagnosis, which is mandatory before planning definitive treatment. **2. Why other options are incorrect:** * **Cone Biopsy:** This is a diagnostic-cum-therapeutic procedure. It is indicated only if colposcopy is unsatisfactory (e.g., the transformation zone is not fully visible), if there is a discrepancy between cytology and biopsy, or to rule out microinvasion. It is not the immediate next step. * **Repeat Pap Smear:** Repeating a screening test in the presence of a positive result and clinical symptoms (contact bleeding) leads to a dangerous delay in diagnosis. * **Hysterectomy:** This is a major surgical treatment. It should never be performed without a confirmed histological diagnosis of the grade and stage of the lesion. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Cervical Biopsy (Colposcopy-directed). * **Triad of Cervical Screening:** Cytology (Pap smear) → Colposcopy → Biopsy. * **Contact Bleeding:** In a perimenopausal woman, always rule out cervical cancer first. * **Atypical Glandular Cells (AGC) on Pap:** These require more aggressive evaluation, often including endocervical curettage and endometrial sampling.

Q: A female patient with a solid ovarian neoplasm developed Meigs syndrome. Which of the following are the components of this triad, EXCEPT?

Pulmonary edema. **Explanation:** **Meigs Syndrome** is a classic clinical triad characterized by the presence of a **benign solid ovarian tumor**, **ascites**, and **pleural effusion**. The syndrome is unique because these features typically suggest advanced malignancy, yet in Meigs syndrome, the condition resolves completely following the surgical removal of the tumor. 1. **Why "Pulmonary Edema" is the correct answer:** Pulmonary edema refers to fluid accumulation within the lung parenchyma (alveoli), usually due to heart failure or systemic fluid overload. In Meigs syndrome, the fluid is **extrapulmonary** (pleural effusion), located in the pleural space. Therefore, pulmonary edema is not a component of the triad. 2. **Analysis of incorrect options:** * **Solid ovarian mass:** The most common tumor associated is an **Ovarian Fibroma** (a benign sex cord-stromal tumor). Other solid tumors like thecomas or Brenner tumors can also cause it. * **Ascites:** Fluid accumulation in the peritoneal cavity is a hallmark. It is thought to result from the tumor surface oozing fluid or pressure on pelvic lymphatics. * **Pleural effusion:** This is typically a **transudate** and is more commonly found on the **right side** (70% of cases). It occurs due to the transfer of ascitic fluid through transdiaphragmatic lymphatics or small diaphragmatic defects. **High-Yield Pearls for NEET-PG:** * **Pseudo-Meigs Syndrome:** A similar triad but associated with other pelvic masses (e.g., ovarian cysts, leiomyomas) or malignant tumors. * **Demons-Meigs Syndrome:** Another name for the same condition. * **Management:** The definitive treatment is **Surgical Excision** of the tumor, which leads to spontaneous resolution of both ascites and effusion. * **Key Histology:** Ovarian fibromas show spindle-shaped cells producing collagen.

Q: A 22-year-old female underwent suction evacuation for molar pregnancy. Beta HCG levels are persistently high following evacuation. What is the next line of management?

Methotrexate. ### Explanation **Correct Answer: D. Methotrexate** **Medical Concept:** The clinical scenario describes **Gestational Trophoblastic Neoplasia (GTN)**. Following suction evacuation of a molar pregnancy, the primary goal of follow-up is to monitor serum $\beta$-hCG levels. If these levels plateau (remain within $\pm$ 10% over three weekly measurements) or rise (increase $>10\%$ over two weekly measurements), it indicates a malignant transformation into GTN (Invasive mole or Choriocarcinoma). In a young patient (22 years old) with persistent $\beta$-hCG, the standard of care is **single-agent chemotherapy**, typically with **Methotrexate** or Actinomycin-D, to preserve fertility and achieve remission. **Analysis of Incorrect Options:** * **A & B (Follow-up/Monitoring):** While monitoring is the standard post-evacuation protocol, it is only appropriate if $\beta$-hCG levels are *falling*. Once levels become "persistently high" or rise, it signifies GTN, and active intervention is mandatory to prevent metastasis. * **C (Hysterectomy):** Although hysterectomy reduces the tumor burden, it is generally reserved for older patients who have completed their family or those with life-threatening hemorrhage. In a 22-year-old, fertility preservation is a priority, making chemotherapy the preferred first-line treatment. **High-Yield Clinical Pearls for NEET-PG:** * **FIGO Criteria for GTN Diagnosis:** 1. $\beta$-hCG plateau for 4 readings over 3 weeks. 2. $\beta$-hCG rise of $>10\%$ for 3 readings over 2 weeks. 3. Persistence of $\beta$-hCG 6 months after evacuation. 4. Histological diagnosis of choriocarcinoma. * **WHO Scoring:** GTN is classified into Low-risk (Score $\leq$ 6) and High-risk (Score $\geq$ 7). Low-risk cases (like this patient) are treated with single-agent Methotrexate. * **Most common site of metastasis:** Lungs (80%), followed by the vagina.

Q: A young girl shows severe dysplasia on cervical cytology. What is the treatment of choice?

Conisation. **Explanation:** The management of cervical dysplasia depends on the severity of the lesion and the patient's clinical profile. In this scenario, **Severe Dysplasia** (equivalent to CIN 3 or HSIL) in a young girl requires definitive diagnostic and therapeutic intervention. **1. Why Conisation is the Correct Answer:** Conisation (Cold Knife Cone or LEEP) is both a diagnostic and therapeutic procedure. For severe dysplasia, it is the treatment of choice because it allows for the complete excision of the **Transformation Zone (TZ)** and the lesion. In young patients, preserving fertility is crucial; conisation removes the abnormal tissue while maintaining the structural integrity of the uterus. It also provides a tissue specimen to rule out occult invasive carcinoma, which cannot be excluded by cytology alone. **2. Why Other Options are Incorrect:** * **Schiller’s Test:** This is a clinical test using Lugol’s iodine to identify non-staining (iodine-negative) areas of the cervix. It is a screening aid, not a treatment. * **Colposcopy:** This is the next step for *evaluating* an abnormal Pap smear to guide biopsies. While essential for diagnosis, it is not a "treatment" for severe dysplasia. * **Repeat Pap Smear:** Severe dysplasia (HSIL) carries a high risk of progression to malignancy. Observation or repeating the smear is inappropriate; immediate histological evaluation and treatment are mandatory. **High-Yield Clinical Pearls for NEET-PG:** * **CIN 1 (Mild):** Usually managed by observation (regresses in 60-80% of cases). * **CIN 2/3 (Moderate to Severe):** Requires excision (Conisation/LEEP) or ablation (Cryotherapy/Laser). * **Transformation Zone:** The most common site for cervical neoplasia; its complete removal is the goal of conisation. * **Young Patients:** Hysterectomy is avoided in young girls to preserve reproductive function unless invasive cancer is confirmed.

Q: Which type of trophoblastic disease has the worst prognosis?

Postpartum. **Explanation:** The prognosis of Gestational Trophoblastic Neoplasia (GTN) is heavily influenced by the nature of the preceding pregnancy. **Postpartum choriocarcinoma** (occurring after a full-term pregnancy) carries the **worst prognosis** among all types of trophoblastic diseases. **1. Why Postpartum is the Correct Answer:** * **Biological Aggression:** Choriocarcinoma following a term pregnancy is often more biologically aggressive and associated with early hematogenous spread. * **Delayed Diagnosis:** Symptoms like irregular vaginal bleeding are often mistaken for normal lochia or retained products of conception, leading to advanced stage at presentation. * **WHO Scoring:** According to the FIGO/WHO scoring system for GTN, a "Term Pregnancy" is assigned the highest risk score (2 points) compared to an abortion (1 point) or a hydatidiform mole (0 points). **2. Analysis of Incorrect Options:** * **B & C (After Spontaneous Abortion/Ectopic Pregnancy):** These carry an intermediate risk. While they can lead to choriocarcinoma, the interval between the event and diagnosis is usually shorter than term pregnancies, and the biological behavior is generally less aggressive. * **D (Hydatidiform Mole):** This has the **best prognosis**. Most cases of Gestational Trophoblastic Disease (GTD) are benign moles. Even if they progress to Gestational Trophoblastic Neoplasia (Persistent Trophoblastic Disease), they are highly sensitive to chemotherapy and often diagnosed early through routine hCG monitoring. **Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Lungs (80%), followed by the vagina (30%). * **FIGO Scoring:** A score of **≥7** indicates High-Risk GTN, requiring multi-agent chemotherapy (EMA-CO regimen). * **Pathognomonic Feature:** Choriocarcinoma is characterized by the absence of chorionic villi and the presence of sheets of syncytiotrophoblasts and cytotrophoblasts with extensive hemorrhage and necrosis.

Q: What is the approximate risk of complex hyperplasia of the endometrium with atypia progressing to malignancy in a postmenopausal woman?

28%. ### Explanation The progression of endometrial hyperplasia to carcinoma is primarily determined by the presence of **cellular atypia**. This classification is traditionally based on the **Kurman classification (1985)**, which remains a high-yield topic for NEET-PG. **1. Why 28% is Correct:** Complex hyperplasia with atypia (also known as Atypical Endometrial Hyperplasia) is the most advanced precursor to Type I Endometrial Adenocarcinoma. Studies by Kurman et al. demonstrated that if left untreated, approximately **29% (rounded to 28% in many texts)** of these cases progress to invasive cancer. Furthermore, there is a high "co-existence" rate; up to 40% of women with this diagnosis are found to have a concurrent invasive carcinoma upon hysterectomy. **2. Analysis of Incorrect Options:** * **3% (Option A):** This represents the risk for **Simple Hyperplasia without atypia**. It has the lowest malignant potential. * **8% (Option B):** This is the risk associated with **Complex Hyperplasia without atypia**. While the architecture is crowded, the lack of nuclear atypia keeps the risk relatively low. * **15% (Option C):** This is the risk for **Simple Hyperplasia with atypia**. The presence of atypia significantly jumps the risk from 1% to 8%–15%. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** For postmenopausal women with atypical hyperplasia, **Total Laparoscopic/Abdominal Hysterectomy** is the treatment of choice due to the high risk of progression and occult malignancy. * **WHO 2014 Classification:** The newer classification simplifies this into two categories: (1) Hyperplasia without atypia (<3% risk) and (2) Atypical Hyperplasia/Endometrial Intraepithelial Neoplasia (EIN) (~30% risk). * **Most Common Symptom:** Abnormal Uterine Bleeding (AUB) or postmenopausal bleeding. * **Risk Factor:** Unopposed estrogen (PCOS, Obesity, Estrogen-only HRT, Granulosa cell tumors).

Question 1

Cigarette smoking and long-term use of oral contraceptives in a woman would most likely predispose to primary cancer in which of the following sites?

Accepted Answer

Cervix

Answer

Breast

Answer

Ovary

Answer

Endometrium

Question 2

A 45-year-old lady complains of contact bleeding and has a positive Pap smear. What is the next line of management?

Accepted Answer

Colposcopy-directed biopsy

Answer

Cone biopsy

Answer

Repeat Pap smear

Answer

Hysterectomy

Question 3

A female patient with a solid ovarian neoplasm developed Meigs syndrome. Which of the following are the components of this triad, EXCEPT?

Accepted Answer

Pulmonary edema

Answer

Pleural effusion

Answer

Ascites

Answer

Solid ovarian mass

Question 4

A 40-year-old woman presents with abnormal cervical cytology on PAP smear suggestive of CIN (III). What is the next best step in management?

Accepted Answer

Colposcopy and LEEP

Answer

Hysterectomy

Answer

Colposcopy and cryotherapy

Answer

Conization

Question 5

A woman is found to have a unilateral invasive carcinoma of the vulva that is 1 cm in diameter with no stromal invasion and is not associated with evidence of lymph node spread. What should be the initial management?

Accepted Answer

Wide excision and Sentinel lymph node biopsy

Answer

Chemotherapy

Answer

Radiation therapy

Answer

Radical vulvectomy and bilateral inguinal lymphadenectomy

Question 6

Which statement regarding the procedure shown below is false?

Accepted Answer

Used to treat high grade cervical intraepithelial neoplasia (CIN)

Answer

Uses freeze-thaw-freeze technique

Answer

Destroys dysplastic epithelium up to a depth of 5mm

Answer

It is an outpatient procedure

Question 7

A 22-year-old female underwent suction evacuation for molar pregnancy. Beta HCG levels are persistently high following evacuation. What is the next line of management?

Accepted Answer

Methotrexate

Answer

Follow up at 1 year

Answer

Monitor until HCG becomes 0

Answer

Hysterectomy

Question 8

A young girl shows severe dysplasia on cervical cytology. What is the treatment of choice?

Accepted Answer

Conisation

Answer

Schiller's test

Answer

Colposcopy

Answer

Repeat pap smear

Question 9

Which type of trophoblastic disease has the worst prognosis?

Accepted Answer

Postpartum

Answer

After spontaneous abortion

Answer

After ectopic pregnancy

Answer

Hydatidiform mole

Question 10

What is the approximate risk of complex hyperplasia of the endometrium with atypia progressing to malignancy in a postmenopausal woman?

Accepted Answer

28%

Answer

3%

Answer

8%

Answer

15%

Gynecologic Oncology — MCQs

Gynecologic Oncology — MCQs

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